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HiolDgraphic 

Sciences 

CorporaliGn 


1.25  III  1.4    IIIII.6 

^ 

6"     

» 

23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14S80 

(716)072-4503 


■  "^'''H| 


K" 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


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Covers  damaged/ 
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Couverture  restaurto  et/ou  pellicul6e 

Cover  title  missing/ 

Le  titre  de  couverture  manque 


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Cartes  gdographiques  en  couleur 

□   Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 


D 
D 
D 


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Bound  with  other  material/ 
Reli6  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distortion 
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pas  6t6  filmdes. 


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modification  dans  la  m6thode  normale  de  filmage 
sont  indiqu6s  ci-dessous. 


D 
D 
D 
D 
D 
D 
D 
D 
D 
D 


Coloured  pages/ 
Pages  de  couleur 

Pages  damaged/ 
Pages  endommagdes 

Pages  restored  and/or  laminated/ 
Pages  restaur6es  et/ou  pellicul6es 

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Comprend  du  materiel  suppl^mentaire 

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obscurcies  par  un  feuillet  d'errata,  une  pelure, 
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obtenir  la  meilleure  image  possible. 


D 


Additional  comments:/ 
Commentaires  8uppl6mentaires: 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film6  au  taux  de  reduction  indiquA  ci-dessous. 

10X  14X  18X  22X 


26X 


30X 


y 


12X 


16X 


20X 


24X 


28X 


32X 


e 

6tail8 
IS  du 
modifier 
ir  une 
ilmage 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

Library  of  Congress 
Photoduplication  Service 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


L'exemplaire  filmA  fut  reproduit  grAce  A  la 
g4n4rosit*  de: 

Library  of  Congress 
Photoduplication  Service 

Las  images  suivantes  ont  At4  reprodultes  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettet*  de  l'exemplaire  filmA,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 


Original  copies  in  printed  papei  jovers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


es 


Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimAe  sont  filmte  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
derniAre  page  qui  comporte  une  empreinte 
d'impresslon  ou  d'lllustratlon,  soit  par  le  second 
plat,  salon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmte  en  commenpant  par  la 
premlAre  page  qui  comporte  une  empreinte 
d'impresslon  ou  d'illustration  et  en  terminant  par 
la  dernlAre  page  qui  comporte  une  teiie 
empreinte. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  —^  (meaning  "CON- 
TINUED "),  or  the  symbol  V  (meaning  "END"), 
whichever  applies. 


Un  das  symboles  suivants  apparaltra  sur  la 
dernlAre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  — ►  signifie  "A  SUIVRE",  le 
symbole  ▼  signifie  "FIN". 


Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  Atre 
filmte  A  dee  taux  de  riduction  diff Arents. 
Lorsque  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seul  clichA,  il  est  filmA  A  partir 
de  I'angle  supArieur  gauche,  de  gauche  A  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  nAcessaire.  Les  diagrammes  suivants 
lllustrent  la  mAthode. 


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?on  A 


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2 

3 

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"1 


LECTURES  ON  FEVERS 


DELIVERED  AT  THE  CHICAGO  IIOM(EOPATHIC 

MEDICAL  COLLEGE,   WITH  A  FEW 

ADDITIONAL  LECTURES 


y 


BY 


JOHN  R.^llPPAX,  M.  D.,  LL.  B. 

Pno™  OP  P„.NC.PLE8  AND  PRACTICE  Or  MEDICNE  AND  MED.OAL  aCRISPHUDENCE 

IN   THE  CHICAGO  HOMCEOPATHIO  MEDICAI.  COLLEGE;  LATE  CLINICAL  LECTUBK.t 

AND  VISITING  PHV8IC1AN  TO  COOK  COUNTr  Ht.PITAL;   MEMBER  OV  THE 

AMERICAN  INSTITUTE   OF   HOMOJOPATHV;    MEMBER    Of  THE  COL- 

LEGE  OP   PHYSICIANS    AND   SURGEONS.  ONTARIO;  ACTHOU 

/   ^^  °^    HAND300K    OP    SKIN    DISEASES;    HTC,    ETC. 


^ 


7 


Sl-^'-cO'-v 


CHICAGO 
GROSS   &   DELBRIDGE 

1884 


r^ 


COPYRIOIITEn  IS?-'', 

BY  GROSS  &  DELP.IUDGE. 

AW.  rfl/h(«  rcscri'cil. 


TO  THE 


ALUMJsI  AND  STUDENTS 


CHICAGO  HOM(EOPATHIC  MEDICAL  COLLEGE, 


TN  WHOSE   BEHALF 


THESE    LECTURES  WEHE  WRITTEN, 


THIS  VOLUME 


IS   DEDICATED   BY   THEIR   FRIENTi, 


THE    AUTHOR. 


maim 


PREFACE. 


These  loctures  contain  the  substnnce  of  tlie  course  on  Fevere, 
delivered  in  the  C!hicago  Honuwopathic  Medical  College  to  tho 
class  of  1882-83.  The  majority  are  formulated  and  enlarged 
from  brief  notes  of  extempore  lectures,  and  are  thuH  stripped  of 
much  of  the  verbiage  incident  to  the  lecture-room.  The  remain- 
der were  not  delivered  in  the  course,  but  have  been  mlded  in 
order  to  make  the  work  more  complete. 

They  are  published  at  the  request  of  students  and  practition- 
ers, who  have  been  from  time  to  time  under  my  instruction,  and 
Avho  have  expressed  a  desire  to  have  them  prepared  in  a  conven- 
ient form  for  reference.  They  contain  information  derived  by 
careful  reading  and  study,  from  the  different  sources  referred  to 
in  the  Bibliography,  for  Avhich  I  desire  to  acknowledge  n>y  in- 
debtedness, combined  with  extensive  personal  observation  and 
experience. 

In  every  instance  I  have  endeavored  to  render  the  exjjosition 
of  all  the  diseases  treated  of,  on  a  level  with  the  science  of  our 
day. 

I  take  special  pleasure  in  expressing  my  obligation  to  mj 
brother,  H.  Kippax,  C.  E.,  of  the  Government  service,  for  his 
valuable  aid  in  preparing  the  drawings  for  the  different  temper- 
ature charts  and  other  illustrations  contained  in  the  work. 

J.  E.  KIPPAX. 

■Chicago,  September,  1883. 


K- 


^ 


:,  ♦ 


I 

i 


CONTENTS. 


LKCTlUi:  I. 

INTIIODUCTION. 


PAOE'- 


Treatment.. 


LECTURE  V. 

SIMPLE  KKMITTENT  FEVER. 

Definition— Synonyms— Historical  Notice-Etiology— Clinical  History— 
Chart— Analysis  of  Chart— Morbid  Anatomy— Differential  Diagnosis 
— Prognosis — Treatment ■ 


29 


Classincntion  ami  description  of  bacteria-Uolc  of  bacteria  in  infections 

and  contagious  maladies- ClaH-Hillciition  of  fevers »•»• 

LECTUKE  II. 

SIMPLE  CONTINMIED  KEVEU. 

Delinition-Synonyms-Etiology-Clinical  Ilistory-Chart-Analysis  of 
Chart- Diircn-ntial  Diagnosis-rrofinosis— Triatinciit— Mularial  !•  e- 
vcrs- The  Nature  of  Mia.sm— Tliermnmclry  of  Fevers 


LECTUKE   111. 

SIMPLE  INTEKMITTK.NT   I'EVKK. 

Definition  -  Synonyms  -  History  -  Clinical  History  -  Ty pcs-Chart- 
Aualysis  of  Chart— Morbid  Anatomy— Dilferential  DiaguoBJH 

LECTURE  IV. 

SIMPLE  INTERMITTENT   FEVER. 


4>* 


^,^ 


(k) 


Miiiwi  nwniriiiiriimamwwTH'iiii'  irr- '"''*"'■  "'''■™*""'^"" 


Tt-  CONTENTS. 

LECTUKE   VI. 

PERNICIOUS   FEVKU 

Dclinition — Synonyms — History — Etiology — Clinical  History — Chart — 
Analysis  of  Cliarl  -Morbid  Anatomy — Differential  Diagnosis — Prog- 
nosis— TreatnitMit 


m 


'    LECTUUE  VII. 

CHUONIC  MALARIAL   INFKCTION. 

Definition — Synonym — Etiology — Clinical  Hi'^tory — Morbid  Anatomy — 
Differential  Diagnosis — Prognosis — Treatment.  Dengue.  Defini- 
tion —  Synonyms  —  History  —  Etiology  — Clinical  History — Chart — 
Analysis  of  Chart — Differential  Diagnosis — Prognosis — Treatment.     100 

:  LECTURE  VIII.  ' 

TVPIIO-MALARIAL  FEVER. 

Definition — Synonyms — History — Etiology— Clinical  History— The  Ma- 
larial Type.  Tlie  Septic  Type — Chart — Anaiysic  of  Chart — Morbid 
Anatomy — Differential  Diagnosis — Prognosis — Treatment Ill 


,,;  LECTUKE  IX. 

HAY    FEVER. 

Definition  —  Synonyms  —  History — Etiology — Clinical  History— Chart- 
Analysis  of  Chart — Differential  Diagnosis— Prognosis — Treatment.. .     123 

LECTURE   X. 

TVPnOID    FEVER. 

Definition — Synonyms— History — Geographical  Distribution — Etiology — 

Clinical  History 136 

LECTURE   XI. 

« 

TYPHOID   FEVER. 

Mild  and  Abortive  Forms  —  Chart — Analysis  of  Chart  —  Duration — Re- 
lapses— Morbid   Anatomy — Differential  Diagnosis — Prognosis 147 

LECTURE  XII. 

TYPHOID    FEVER. 

Treatment > 172 


:iiart— 
— Prog- 


8» 


itomy — 

Defini- 

Chart— 

tment. . 


100 


'he  Ma- 
-Morbid 


111 


Chart 
ment. 


CONTENTS.  . 

LECTURE  XIII.  ., 

YELLOW     FEVER. 

Definition— Synonyms— History— Geographical  Limits — Etiology— Clin- 
ical History— Chart — Analysis  of  Chart — Morbid  Anatomy 105 

LECTURE  XIV. 

.'■-■■■■  .  ;>,..'■'-*■        ■   •  ■  '  - 

YELLOW     FEVEK.  ' 

Diflferential  Diagnosis — Prognosis — Treatment 210 

LECTURE  XV. 

CEKEBKO-SPINAL   FEVER. 

Delinition— Synonyms— History— Etiology — Varieties— Clinical  History 
—Chart— Analysis  of  Chart— Complications  and  Sequels— Morbid 
Anatomy — Differential  Diagnosis — Prognosis 223 

''  LECTURE  XVL 

CEREBRO-SPINAL  FEVER. 

Treatment. 239 

LECTURE  XVII. 

INFLUENZA. 

Definition— Synonyms— History-Etiology— Clinical  History—  Chart- 
Analysis  of  Chart  — Morbid  Anatomy  —  Differential  Diagnosis  — 
Prognosis — Treatment 253 

LECTURE  XVIIL 

TYPHUS  FEVER. 

Definition— Synonyms— History— Geographical  Limits— Etiology—  Clin- 
ical History— Complications— Chart— Analysis  of  Chart- Morbid 
Anatomy 272 

LECTURE  XIX. 

TYPHUS    FEVER. 

Differential  Diagnosis — Prognosis — Treatment 091 

LECTURE  XX. 

RELAPSING   FEVER. 

Definition— Synonyms— History— Etiology  —  Clinical  History—  Chart- 
Analysis  of  Cliart— Morbid  Anatomy— Differential  Diagnosis— Prog- 
nosis— Treament 307 


li 


--Or-CT1ff  ■"^-|T'''f*'^'^'^""'1— 


Xii  CONTENTS. 

LECTURE  XXI. 

SMALL-POX. 

Delinition— Synonyms— History-Etiolocy- Varieties— Clinical  History 
— C'onthuMit  Small-Pox— llfiuonliasjic  Small-1'ox— Complications— 
Cluirt— Analysis  of  Chart 331 

LECTURE  XXn. 

SMALL-POX. 

Morbid  Anatomy— Differential  Diagnosis— Prognosis— Treatment 347 

if  LECTURE  XXIIL 

VARIOLOID    AND   VACCINATION. 

Cow-Pox.  Definition— Synonyms— History— Etiology— Clinical  History. 
HousE-Pox.  Vaccinia.  Definition— Synonym— Clinical  His — 
tory— Irregularities— Complications.  Inoculation  Definition— 
History— Clinical  History— Mortality.  Vaccination-  Delinitiou— 
History— Prophylactic  Influence— Virus-  Re-vaccination— Surgery 
of  Vaccination.  Varioloid.  Definition— Syuouym— Etiology— 
Clinical  History-Chart— Analysis  of  Chart— Differential  Diagnosis 
— Prognosis — Treatment 360 

■      '■    LECTURE  XXIV. 

•'  CHICKEN- rOX. 

Definition  —  Synonyms— History— Etiology— Clinical  History—  Chart— 
Duration— Differential  Diaguosis-Prognoeis-Treatment.  Miliary 
Fever.  Definition— Synonyms— History— Etiology— Clinical  His- 
tory—Duration—Morbid Anatomy— Differential  Diagnosis— Progno- 
sis—Treatment  371 

LECTURE  XXV. 

MEASLES. 

Definition— Synonyms— History— Etiology— Clinical  History— Duration 
—Irregular  Types— Malignant  Measles— Complications  and  Sequels- 
Chart— Analysis  of  Chart— Morbid  Anatomy 379 

LECTURE  XXVI. 

MEASLES. 

Differential  Diagnosis— Prognosis— Treatment 390 


tuiuiimtiiiiiiu 


36a 


CONTF.NTS.  iW 

LECTl-KK  XXVll. 

UEKMAX    MIOASI.KS. 

Dcilnition— Synonyms  — History— Ktiolojiy— Clinical   Histt)ry— C'liait  — 

Morbid  Auatoiuy— Dillerential  Uiasuosis— Prognosis— 'I'nul mini. . .     399 

,     LKCTUKE  XXVIII. 

SCAUI.KT    KKVKK. 

Definition— Synonyms— History— Etiology- Forms— Clinical    Hi.nory—    - 
Irregularities— (^Complications  anil  Scqiu'ls 404 

.,  .  •  LECTUKK  XXIX. 

SCAKI.KT     IKVER. 

Chart- Analysis  of  Chart— Morbid    Anatomy— Did'erential    Diagnosis— 

„  '  414 

Pro;;nosis 

LECTURE  XXX.  : 

SCAUI.KT     n;VKI{ 

Treatment '*-"' 

BlBLIOaRAVIIY '*'*^ 

Index ^^'^ 


i 


371 


379 


390 


f  ■   I  i-ff"-"^!"-""-*^'"'^'"' •'''■' ''Y'''"''"'^' 


LECTURES  ON  FEVERS. 


LECTURE  I. 

INTRODUCTORY. 


Gentlemen: — We  will  begin  the  present  course  of  lectures  on 
the  practice  of  medicine,  by  considering  the  nature  of  that  class 
of  human  ailments  which  have  from  early  times  been  known  as 
The  Fevers.  Special  causes,  more  or  less  independent  in 
character,  and  possessing  vaguely  defined  properties,  appear 
on  the  record  books  of  the  past,  as  operating  to  produce  out- 
breaks of  these  maladies. 

To-day,  writers  on  febrile  affections  are  pleased  to  term  the 
morbific  agents  which  give  rise  to  the  fevers,  and  tu  infectious 
and  contagious  diseases  generally,  viruses.  The  organized  nat- 
ure of  these  viruses,  and  the  exact  relation  of  bacteria  as  con- 
veyors and  originators  of  contagion,  are  the  problems  that  are 
now  undergoing  solution. 

Time,  the  destroyer  of  creeds  and  leveler  of  unfounded  the- 
ories, will  afford,  if  not  to  us,  at  least  to  our  successors,  a  demon- 
stration of  the  truth  or  falsity  of  the  popular  parasitic  theory 
of  the  causes  of  infectious  diseases. 

The  medical  world  has  ever  been  in  a  state  of  unrest  as  to  the 
origin  of  Fevers.  Away  back  in  the  ages  of  antiquity,  medical 
savants  found  the  ordinary  theories  entirely  insufficient  to  ac- 
count for  the  peculiar  phenomena  attending  outbreaks  of  these 
diseases.  Hence  we  find  them  conjuring  up  a  "  constituiio  pes- 
iilens"  or  a  "genus  epidemicus,"  to  ease  their  minds  and  ex- 
plain the  mystery.    Astrological  influences,  electrical  displays, 

15 


."•a' ■iiliSi^'i'y''^  ■ ' 


_..»^ 


10 


LECTURES  ON   FEVEK8. 


and  atmospheric  changes,  have  each  and  all  been  looked  to  in 
their  time,  but  still  in  vain. 

The  early  Roman  writers  unconsciously  touched  the  key-note 
when  they  attributed  the  origin  of  malarial  fevers  to  the  entrance 
of  low  organisms  into  the  body.  But  it  was  left  to  Leuwen- 
hoek,  the  father  of  microscopy,  and  the  Columbus  of  the  new 
world  of  microscopic  flora,  to  outline  the  bold  hypothesis  of  a 
contaijium  vivnm,  against  which  no  other  valid  objection  can, 
after  the  lapse  of  two  centuries,  b6  raised,  than  that  in  a  number 
of  infectious  and  contagious  diseases  its  existence  has  not  as 
yet  been  absolutely  demonstrated. 

Bacteiiia  (from  balcirrion,  a  little  rod  or  staff),  the  smallest 
and  at  the  same  time  the  simplest  and  lowest  of  all  living  forms, 
were  first  perceived  by  Leuwenhoek  in  1675.  They  were  at  that 
time  classed  under  the  general  head  ivfiisona,  and  were  for  years 
ccmsidered  as  animals  and  placed  at  the  foot  of  the  series.  Their 
correct  place  in  the  scale  of  organisms  was  given  them  in  1859 
by  M.  Davaine,  who  first  demonstrated  their  vegetable  nature, 
and  in  1863  made  known  his  discovery  of  microscopic  organisms 
in  contagious  diseases. 

The  positive  characteristic  that  bacteria  are  not  animal  be- 
ings, is  the  fact  that  concentrated  acetic  acid,  which  causes  all 
animal  tissues  to  become  pale,  has  no  action  on  bacteria. 

The  history  of  these  minute  organisms  is  of  more  than  ordi- 
nary interest  to  medical  men,  on  account  of  their  close  relation 
to  the  formation  and  diffusion  of  virtises,  and  hence  to  the  pa- 
thogeny, sanitation,  and  hygienic  treatment  of  a  great  number 
of  human  ailments. 

A  short  description  of  them  here,  may  not  be  without  profit. 
Botanists,  who  have  most  recently  occupied  themselves  with 
bacteria,  define  them  as  "cells  deprived  of  chlorophyll,  of  glob- 
ular, oblong  or  cylindrical  form,  sometimes  sinuous  and  twisted, 
reproducing  themselves  exclusively  by  transverse  division,  and 
living  in  isolated  or  cellular  families;"  and  though  they  possess 
affinities  which  approach  them  to  the  alga;  yet  the  absence  of 
chlorophyll — which  is  present  in  the  algia — necessitates  their  be- 
ing classed  among  the  fimgi 

They  exist  in  their  separate  state  in  two  principal  forms:  glob- 
ular bodies,  or  monads,  and  bodies  more  or  less  filiform,  or  bac- 
leria,  properly  so  called. 


:ed  to  in 

key-note 
entrance 
Leuwen- 

the  new 
2sis  of  a 
ion  can, 

number 
,s  not  as 

smallest 
ig  forms, 
re  at  tliat 
for  years 
s.  Their 
1  in  1859 
e  nature, 
rganisms 

(liraal  be- 

3auses  all 

a. 

ban  ordi- 

*  relation 

to  the  pa- 

t  number 

lut  profit. 
Blves  with 
1,  of  glob- 
d  twisted, 
ision,  and 
ey  possess 
absence  of 
s  their  be- 

rms:  glob- 
•m,  or  bac- 


BACTEBIA. 


17 


M.  Cohn,  of  Breslau,  the  eminent  naturalist  and  student  of 
inferior  organisms,  recognizes  six  genera  of  bacteria: 


Fia.  1. 


v~  •,. 


•  ••• 


•oaeeo* 


(From  Microscop- 


Microeoccus,  ball  or  egg-shaped  bacteria.    650  diameters. 

ical  Jouroal.) 

These  are  the  smallest  bacteria,  and  unlike  all  other  forms, 
are  not  characterized  by  periods  of  repose  and  movement. 

When  rapidly  multiplying  they  are  frequently  found  grouped 
in  gelatinous  masses. 

Fig.  2. 


'^ff 


0 


%    ^      %t    ^   ^^<o 


\l 


I 


Bacterium,  short,  rod-like  bacteria.    650  Diameters 

Journal.) 

Magnin  says,  bacteria  spores  are  the  point  of  departure  of 
epidemic  foci,  and  their  extreme  lightness  explains  how  readily 
ihey  are  disseminated  by  the  wind. 

Fig.  3. 

'^1 1  i''i>tH  1 1  '^f 


Bacillus,  straight,  fibre-like  bacteria.     650  Diameters.     (From  Microscopical 

Journal.) 

The  spirilla  are  the  largest  of  the  bacteria,  and  attain  the 
length  of  two-tenths  of  a  millimeter,  (p.  310) 

The  filiform  bacteria,  and  the  spirilla,  unlike  the  micrococ- 
ci, are  never  found  in  gelatinous  masses,  but  may  be  found  in 
active  swarms. 


J'. 


smesmmmmsesm^^r--^ 


twji  ■iJit.ititimm  ■'     - 


18 


LECTURES  ON   FEVE118. 


1:    i 


As  is  the  case  with  all  livinji  orpfinisms,  bncteria  poBsess 
tho  power  of  8ol£-i>ro,mgution.  This  is  done  by  l.i-partition  or 
fisaioii. 

Fid.  ». 


-^nJ 


X  I 


SSB»*^  r  \ 


BariUus  3Ialaria:,  (after  Klebs  and  Tommasi-Crudeli.) 


Fig.  5. 


ill 


■»ifl 


Vibrio,  wavy,  curl-like  bacteria.  G50  Diameters.    (From 
Microscopical  Journal.) 

SpirochiBti  are  long,  flexible,  spiral  bacteria. 


BACTEIIIA. 


19 


a  poBsess 
artition  or 


1^ 
I 


li.) 


From 


A  groat  part  of  the  whitish  slimo  that  collects  on  the  teeth  in 
composed  of  vibrios.  Vibrios  are  also  found  in  swurms  in  chole- 
raic dischaiges. 

"When  a  bacterium  has  grown  to  about  double  its  ordinary 
dimensions,  constriction  takes  place  at  the  middle  and  it  is  brok- 
en in  two.     Each  half  following  the  parent  cell  reaches  matu- 


Fni.  (!. 


WCi^^ 


t^ 


^ 


<^^^ 


spirillum,  sliort,  screw-liko  bacteria.    050  Diameters. 
Microscopical  Journal.) 


(From 


Tity  in  a  short  time,  and  similarly  divides.  So  rapidly  may  this 
division  be  performed  that  in  one  hour  the  separation  may  be 
complete.  Other  things  being  equal  the  warmer  the  atmosphere 
the  more  rapidly  does  the  division  proceed.  With  a  lowering 
temperature  it  becomes  slower  and  slower  and  finally  ceases  at 
the  neighborhood  of  the  freezing  point. 

The  bacterial  germs  are  found  to  differ  widely  among  them- 
selves as  regards  their  preparedness  for  development.  And  the 
degree  of  preparedness  applied  to  either  a  ferment,  an  infection 
or  a  contagion,  decides  whether  the  hatching  period  shall  be 
long  or  short. 

Recent  experiments  concerning  the  "  death-point"  of  bacteria 
have  demonstrated  that  these  organisms  are  capable  of  resisting 
even  marked  changes  of  temperature,  provided  the  changes  are 
not  sudden  but  gradual.  They  will  endure  an  elevation  of  tem- 
perature to  130O  Fahr.  or  even  to  176°  Fahr. ;  a.*i  gradual  freezing 
only  benumbs  them, — it  does  not  destroy  tjiem. 

And  further,  it  may  be  stated  that  even  desiccation  if  not  too 
prolonged,  will  not  kill  them,  but  will  simply  arrest  their  activ- 
ity. Their  vitality  is  not  destroyed,  for  under  favorable  condi- 
tions of  moi-^+ure  and  warmth,  this  will  again  assert  itself.  The 
tenacity  of  life  exhibited  by  the  micrococci  in  the  virus  of  con- 
tagious diseases  well  exemplifies  this  fact. 


^■^.  lumMJMmm 


'20 


LECTUBEa  ON   I'EVEIW. 


But  here,  ns  elsewhere  in  the  stuily  of  BiogonesiB,  it  is  well 
to  benr  in  mind  the  dififorenco  in  resistive  power  posseBSPtl  by 
the  germ,  and  by  the  finished  bncterium.  For,  other  things  be- 
ing equal,  the  nearer  the  germ  is  to  its  finished  sensitive  condi- 
tion, the  more  readily  will  it  succumb  to  atmospheric  changes. 

Ozone  affects  bacteria  by  arresting  their  formation,  while  car- 
bonic  acid  tempo'-nrily  paralyzes  thera.    Boracic  acid  kills  them» 
by  depriving  the  a  of  oxygen;  and  one-twentieth  per  cent,  of 
carbylic  acid  will  t  ffectually  prevent  their  development. 

Bacteria  receive  their  nutriment  and  respire  by  "endos- 
motic  absorption."  They  require  a  certain  amount  of  tvatcr,  ox- 
y<)cn,  carbon  and  niirogen,  as  nutrient  material,  and  a  certain 
average  degree  of  temperature  for  germination.  The  water  they 
take  up  from  the  liquids  in  which  they  develop,  or  from  the 
damp  surfaces  on  which  they  are  formed.  The  oxygen  they 
take  from  the  atmosphere;  hence  it  follows  that  without  free 
access  of  air  there  can  be  no  life  and  no  development.  The  car- 
bon may  be  taken  from  any  organic  substance  containing  it,  but 
not  from  carbonic  acid.  And  the  nitrogen  may  be  taken  in 
the  form  of  either  albumen  or  ammonia. 

Bacterial  forms  are  found  everywhere,  but  develop  in  masses 
only  when  decomposition  and  fermentation  or  putrefaction  are 
l)resent.  According  to  Naegeli,  a  distinguished  German  bota- 
nist, they  are  not  the  chance  companions  of  putrefaction,  but  are 
the  fungi  which  produce  it.  "Putrefaction,,"  says  Cohn,  "  is  a 
chemical  process  excited  by  Bacteria.  Death  does  not  as  is  fre- 
quently supposed,  cause  putrefaction,  but  rather  it  is  caused  by 
the  life  of  these  invisible  organisms." 

'*  The  whole  arrangement  of  nature  is  based  on  this,  that  the 
body  in  which  life  has  been  extinguished  succumbs  to  dissolu- 
tion, in  order  that  its  material  may  become  again  serviceable  to 
new  life.  If  the  amount  of  material  which  can  be  moulded  into 
human  beings  is  limited  on  earth,  the  same  particles  of  material 
must  ever  be  converted  from  dead  into  living  bodies  in  an  eter- 
nal circle." 

A  striking  parallelism  exists  between  the  known  phenomena 
of  putrefaction  or  fermentation,  and  those  of  infectious  and 
contn<noas  diseases.    But,  at  the  same  time,  there  is  an  acknowl- 


MMWUJ!-^-^--""'"'" 


LACTEIIIA. 


tl 


,g,  it  is  well 
0886880(1  by 
r  things  be- 
jitive  coiidi- 
rio  changoa. 

D,  while  car- 
i  kills  theii% 
per  cent,  of 
ent. 

by  "endos- 
of  ivaier,  ox- 
ad  a  certain 
lie  water  they 
or  from  the 
oxygen  they 
without  free 
at.  The  car- 
aining  it,  but 
be  taken  in 


3p  in  massea 
refaction  are 
German  bota- 
ction,  but  are 
s  Cohn,  "  is  a 
,  not  as  is  f  re- 
t  is  caused  by 

this,  that  the 
bs  to  dissolu- 
serviceable  to 
I  moulded  into 
les  of  material 
ies  in  an  eter- 

m  phenomena 
infectious  and 
is  an  acknowl- 


edged differenco  between  the  bacteria  of  contagion  and  tho  bac- 
teria of  putrefaction.  The  former  are  distiuguiahed  by  thoir  lUf- 
ferent  form,  size,  and  habits  of  life.  Oftentimes  they  battle  for 
existence  with  the  putrefaction  bacteria  and  are  by  them  exter- 
minated if  they  are  conquered. 

Declat  alludes  to  this  parallelism  when  he  says,  "the  role  of 
bacteria  is  not  limited  to  putrefaction.  They  also  invade  the 
living  organism  and  bring  in  their  attack  the  double  character  of 
inhnite  smallness  in  their  apparent  moans  and  jxiwerful  destruc- 
tive energy  in  the  results.  From  this  source  come  diseaiies  of 
M'hich  man  not  long  since  did  not  know  the  cause,  and  which  he 
only  commences  to  refer  to  their  veritable  origin.  For  those 
who  are  an  couranf  with  the  first  steps  which  she  has  made  in 
this  new  line  of  research,  with  the  fecundity  of  her  first  glimpses, 
with  the  richness  of  her  first  results,  it  is  not  doubtful  thot  she 
will  soon  succeed  in  demonstrating  the  parasitic  nature  of  the 
gravest  epidemic  maladies." 

Our  atmosphere  contains  few,  if  any,  adult  bacteria,  but  al- 
ways more  or  less  permanent  spores,  which  float  in  groups  or 
clouds,  and  are  presumed  to  have  escaped  from  sporogenous 
filaments  of  the  bacteria. 

These  ultra-microscopic  germs  or  particles,*  possessed  with  a 
power  of  flotation  commensurate  with  their  smallness  and  light- 
ness, are  the  supixjsed  origin  of  all  bacterial  life. 

Miquel  found  that  the  average  number  of  microbes  in  the  air 
is  feeble  in  winter,  and  augments  rapidly  in  the  spring.  Bain 
always  diminishes  the  number  of  true  microbes. 

Water  contains  considerable  quantities  of  bacteria,  and  more 
■especially  of  germinal  particles.  The  water  of  our  rivers  and 
lakes  is  always  fecund  and  may  give  birth  to  several  species  of 
bacteria.  The  only  waters  which  do  not  contain  them  are  those 
drawn  from  the  very  source  of  the  spring,  as  our  artesian  and 
mineral  spring  waters. 

The  weight  of  a  bacterium  has  been  calculated  at  0.000,000,001,- 
57  milligram.  This  extreme  lightness  suggests  a  possible  ex- 
planation of  the  occasional  appearance  of  new  diseases  in  the 
•world.    Prof.  Cohn  considers  it  not  unreasonable  to  suppose 

*  A  particle  has  been  defined  as  "  a  bit  of  liqnid  or  solid  matter,  formed  by 
the  aggregation  of  atoms  or  molecules."  An  atom  or  molecule  if  free,  is  always 
part  of  a  gas,  the  particle  is  never  so. 


22 


LKiTi-uEs  OS  rKVF.na. 


thnt  s.nall  i.artic-l.H  of  Imct.-rinl  .lust  amy.  while  Uoatin;^  in  the 

tho  .ittnu-ti.m  of  our  phiuot  uiul  wand.T  into  npaco.  .uul  thu  i^h 
Hnll.ll.yU.mlin-  for  un  inaoliuit..  tinin  throu-h  sp,u'.-.  it  is 
p.Hsil.h'  fur  thos.«  p,.rticl.-s  to  at  iMHt  r-m-h  tho  utnio.ph.'i.M.t 
c.ther  worl.ls  .mil  ihul  th.-io  ciuUtiouH  f.ivorublo  to  thoir  ilovol- 

opmi'ut,  multipliciition  iuhI  t,'ro\vth. 
VncTHiuK  thoora.ritiHn..tmonMiuronKonnblotoHuppoH«t Imt 

gerniH  or  purtidcK  currio.l  b.yoncl  tin-  uttracUou  of  other  worhlB 
nmy.  after  ni.>vinK  about  in  npace,  ovoutually  reach  our  a  mos- 
phuro,  a.ul  rnuling  it  congenial  to  thoir  clovolopmcut.  multiply 

and  till  t\u'  earth.  .  ,      ^     •  ,  i-c    • 

Passing   from  this  desultory  description  of  bac  orml  Ufo  n. 
Konoral,  to  u  moro  direct  co.midoratioa  of  tho  position  it  occu- 
pies   in  the  causation  of  inf.K.tioU8  and  contagious  maladies, 
lot  me  say  to  you  that  we  have  us  yet  little  positive  knmvl- 
cd.re,   but     trust    tlu,    futu.o  is  pregnant  with  corroborative 
facets.     That  advanced  guard  of  tho  medical  profession  -its  suc- 
cessful workers  and  profound  think.>rs  -are  busy  night  and  day 
Ht  the  chaos,  and  oven  now  the  light  begins  t.>  dawn.     In    their 
nxperiments  ..n  sei.ticomia  Coze  and  Feltz  were  driven  to  admit 
that  "there  is  a  direct  relation  between  tho  infectious  accidents 
and  the  foreign  organisms  (micrococci)  which  play  in  the  blood 
tho  role  of  ferments  and  reproduce  themselves.      1  asteur,  the 
accomplished  French  experimenter,  justly  claims  tho  honor  of 
being  the  first  to  suggest  tho  possibility  of  the  parasitic  nature 
of  septicii'inia. 

Dr  Eklund  of  Stockholm,  found  flat,  oval  or  rounded  aporoid- 
al  cells,  termed  plax  scindons  in  the  urine  and  blood  of  scarlet 
fever  patients.  The  plax  scindens  multiplies  as  do  bacteria  in 
general,  and  belongs  to  the  order  of  schizomycetes  or  clett-fungi 
as  adopted  by  Naegeli.  These  cellular  bodies  are  peculiar  to 
scarlet  fever,  and  are  not  found  in  any  other  disease,  (p.  4  »o). 

Bacteriform  elements  have  been  discovered  in  the  nasal  mu- 
cus of  measles  during  the  stage  of  invasion,  and  active,  slender 
rods  have  been  unmistakably  noticed  in  the  blood  of  patients 
suffering  from  this  .lisease.  The  parasitic  nature  of  diphtherifv 
is  to-day  acknowledged  by  all.  But  it  is  yet  a  mootea  question 
whether  a  bacterium  or  a  micrococcus  is  the  agent  of  contagion. 
The  bacillus  a.  thracis  has  been  definitely  outlined  as  the  cause 


->'  :s^ftnA^KJAjas-'  > 


oi:lUIN  01'  I'EVElb*. 


'11 


tin;^  ill  tlie 
air  lH>yt)iul 
,iul  thl>^l^^h 
ipiu'f,  it  in 

hoir  Jevol- 

ippoHH  that 
;hor  worldrt 
our  ntniort- 
,t,  multiply 

irial  life  iu 
on  it  occu- 
i  umlialit^rt, 
;ivo  kmnvl- 
rroboriitive 
jn— its  8UC- 
»ht  and  duy 
.     In    tluiir 
en  to  admit 
IS  accidouts 
in  the  blood 
?a8tt!ur,  tlio 
le  honor  of 
sitic  nature 

:led  aporoid- 
id  o£  scarlet 
5  bacteria  in 
r  clot't-fungi 

peculiar  to 
3.  (p.  405). 
le  nasal  mu- 
tive,  slender 

of  patients 
f  diplitherif* 
ted  question 
jf  contagion, 
as  tbe  cause 


of  cliarboii.  Tlio  viruU'Uoo  of  variola  Ims  Ik>.  it  attribnt.l  to  ,t 
bnctorium,  thou^^ii  tli.'  iniij.-rity  .-f  Irsfiiurtiy  o.f i(<l-ni;.u«s  lli." 
demonstrations  of  Cliauvfau  and  Ivkbs,  wj.irif  uutliui'  U  us 
miorocoii'iis. 

Ti^ri  liist  dtMmmstnit.'d  the  pros('n.'.>  of  bacteria  in  tliO  b)"^d 

oF  typhoid  I'cver  patients,  and  nion-  rtTrntly  K)'''-^  fUid^  Kl>,-;t!i 

have  I'oiih.l  a  bacillus  which  they  claim  to  Ite  the  :.p.ciiic  virUM. 

Tiie  latter  ohscrvcrs  I'oiukI   rod-shaped  orjLranisms  smaller  than 

those  of  anthras.    in   the    lymphatic  glands  an.l  vessels  in  the 

vicinity  of  typhoid  ulcers. 

Co/e  and  l-'elt/ have  shown  by  ex[)erimentat  ion  that  inoculation 

with  tho  blood  of  typhoid  fiver  produce.l  in  rabbits  the  charac- 
teristic pathoh)«ieai  condition  in  the  ylands  of  I'eyer. 

The  micrococci  frecpiently  found  in  thr  dejccbi  of  typhoid 
fever  patients  cannot  be  held  as  characteristic,  as  they  an^  fri-- 
(juently  se<'n  hi  the  fieces  of  healthy  individuals. 

Obermeier  hi  iHtW  discovered  c(>itain  wavy,  thread-like  bodies, 
calletl  spirilla,  in  the  blood  of  relapsiii|.;  feviT  patients  tbirin^; 
tht)  access  of  the  fever. 

Neisser,  of  Leipsic,  has  discovered  a  very  small  bacillus  m 
the  nodes  of  the  skin  in  leprosy,  and  has  further  discovered 
micrococci  in  the  specitic  virus  of  gouorrhcea.  A  form  of  schi- 
zomycetes  or  cleft-fungi  has  been  detected  in  the  i)ia  mater  of 
cerebro-spuial  fever  victims. 

Gerber  and  Birsch-Hirschfelder  have  recently  found  bacterial 
cori)Uscles  covering  the  valves  oi  the  heart  in  ulcerative  enilo- 
carditis.  Yon  Recklinghausen  and  Lukomsky  have  discovered 
a  micro-organism  in  erysipelas.  And  Friedlan«ler,  of  Berlin, 
the  latest  hivestigator  as  to  pneumonia,  has  found  micro-organ- 
isms in  that  disease.  The  latter  describes  ellipsoidal  micrococci 
about  a  micro-millimeter  in  length,  and  one-third  less  in  breadth, 
arranged  in  pairs  or  long  chains,  as  being  specially  abundant 
during  the  stage  of  red  hepatization. 

Koch,  Tousaaint  and  Watson  Cheyne,  have  recently  discov- 
ered the  true  micro-organism  which  induces  tubercular  dis- 
eases. They  describe  the  tubercle  bacillus  as  being  more  slen- 
der  and  pointed  than  the  leprosy  bacillus,  and  as  having  a  length 
of  from  one-third  to  one-half  the  diameter  of  a  red  corpuscle. 
These  bacilli  develop  most  rapidly  at  a  temperature  of  from  8<)° 
Fahr.  to  106'  Fahr.,  and  in  this  respect  differ  markedly  from  the 


24 


LECTURES  ON  FEVERS. 


,    i 


,1: 


bacilli  of  splenic  fever  which  develop  rapidly  at  low  temperatures. 
Professors  Klebs  and  Tommassi-Criideli,  of  Eome,  Italy, 
claim  to  have  found  the  malarial  microbe — the  true  bacillus 
malaria).  But  the  recent  experiments  of  Dr.  Sternberg,  with 
malaria,  in  the  vicinity  of  New  Orleans,  appear  to  only  partially 
support  their  statements.  The  former  found  the  bacillus  mala- 
rias not  only  in  malarial  soil,  but  hlso  in  the  blood  of  patients 
Buflfering  from  intermittent  fever. 

From  these  results  of  a  few  of  the  experiments  made  during 
the  last  decade,  you  will  readily  understand  why  the  parasitic 
theory  of  the  origin  of  infectious  and  contagious  diseases  as  op- 
posed tq  the  physiologio-chemical,  is  rapidly  gaining  support. 
The  physiologio-cliemical  theory,  which  is  supported  mainly  by 
negative  argument,  maintains  that  chemical  changes  take  place 
in  the  system,  jiroducing  morbid  results,  after  the  introduction 
of  the  infectious  elements  into  the  blood,  upon  the  principle  of 
catalysis. 

The  germ  or  parasitic  theory  maintains  that  the  infectious 
and  contagious  poisons  are  living  organisms  which,  being  intro- 
duced into  the  blood,  develop  and  reproduce  themselves,  and  by 
their  development  and  reproduction  give  rise  to  morbid  changes 
and  groups  of  symptoms  that  are  characteristic  of  types  of  dis- 
ease. Owing  to  the  present  uncertain  state  of  medical  knowl- 
edge, and  the  absence  of  positive  evidence  as  to  the  exact  nature 
and  habits  of  these  organisms,  advocates  of  the  germ  theory  are 
themselves  divided  on  the  unity  or  multiplicity  of  pathogenic 
fungi. 

One  school,  at  the  head  of  which  stands  Naegeli,  of  Munich, 
holds  that  the  same  species  of  fungi,  differing  in  form  through 
various  generations,  both  morphologically  and  physiologically, 
may  cause  the  different  infectious  and  contagious  diseases. 
This  belief  is  based  principally  on  the  experiments  of  Buchner 
and  Pasteur,  who  believed  that  by  repeated  propagation  the 
virulent  bacillus  anthracis  could  be  changed  into  a  harmless  hay 
bacillus,  and  reversely  that  the  harmless  bacillus  foeni  could,  by 
repeated  propagation  and  culture,  be  made  to  possess  the  viru- 
lent properties  of  the  bacillus  anthracis.  The  recent  labors  of 
Koch  and  his  pupils  have,  however,  thrown  great  discredit  on 
these  experiments  by  demonstrating  that  Buchner  was  not  suffi- 


ciently careful  in  mak' 


•g  them. 


For,  by  repeated  experiments 


M. 


•-;<aKa»>r.«!a'^»TSi(nBSiW^ffl»WaBB*!E^^ 


ORIGIN  OF  FEVERS. 


25 


w  temperatures. 
I  Rome,  Italy, 
le  true  bacillus 
Sternberg,  with 

0  only  partially 
i  bacillus  mala- 
>od  of  patients 

ts  made  during 
ly  the  parasitic 

1  diseases  as  op- 
jaining  support, 
•orted  mainly  by 
mges  take  place 
the  introduction 

the  principle  of 

it  the  infectious 
ich,  being  intro- 
smselves,  and  by 
I  morbid  changes 
!  of  types  of  dis- 
E  medical  knowl- 
I  the  exact  nature 
germ  theory  are 
tyof  pathogenic 

}geli,  of  Munich, 
in  form  through 
i  physiologically, 
tagious  diseases, 
lents  of  Buchner 
propagation  the 
ito  a  harmless  hay 
us  fceni  could,  by 
possess  the  viru- 
B  recent  labors  of 
great  discredit,  on 
iner  was  not  suffi- 
sated  experiments 


the  former  were  able  to  propagate  either  bacillus  indefinitely, 
without  in  the  slightest  degree  changing  its  nature. 

The  other  school,  which  is  rapidly  gaining  adherents,  and  has 
suddenly  become  the  popular  one  of  to-day,  holds  tliat  each  in- 
fectious or  contagious  disease  has  its  virus  in  a  well-defined  and 
separate  germ,  capable  of  reproducing  itself  under  favorable 
conditions,  and  always  causing  the  same  morbid  changes,  and 
producing  invariably  the  same  distinct  specific  disease. 

Clinical  experience  bears  us  out  in  giving  greater  credence  to 
the  theory  of  this  latter  school.     For  as  far  back  as  we  have  any 
authentic  records,  small-pox  has  always  been  small-pox,  and  has 
ever  been  described  as  having  the  same  general  symptoms  which 
characterize  it  to-day.     So  it  has  been  with  scarlet  fever;  and  so 
It  18  with  measles  and  the  rest.    As  surely  as  the  mustard  plant 
arises  from  the  mustard  seed,  as  surely  as  the  oat  springs  from 
oat,  the  peach  from  the  peach,  and  oaks  from  little  acorns  grow 
so  surely  does  the  small-pox  virus  (or  seed)  increase  and  mul- 
tiply into  small-pox,  the  scarlet  fever  virus  into  scarlet  fever, 
and  the  typhoid  virus  into  typhoid  fever.     True  it  may  be  that 
some  symptoms  of  these  maladies  may  appear  more  prominent 
m  certain  epidemics  than  in  others,  and  that  in  the  course  of 
time  certain  infectious  diseases  may  have  become  somewhat 
modified;  yet  it  is  equally  true  that  the  characteristics  of  these 
diseases  have  always  remained  the  same,  and  that  one  infectious 
or  contagious  disease  has  never  been  known  to  be  transformed 
into  another.     Could  different  forms  of  the  same  fungus  cause 
these  varied  ailments,  it  would  be  a  rational  expectation  that 
changes  from  one  form  to  another  might  take  place  in  the  body 
of  the  patient,     that  a  case  beginning  as  measles  might  end,  say 
as  scarlet  fever,  or  perchance  small-pox,  and  that  an  epidemic 
might  readily  change  its  nature  during  any  part  of  its  course. 
Suffice  it  to  affirm  that  from  the  dim   twilight  of   antiquity 
down  to  the  present  time  no  such  transition  has  ever  been  ob- 
served. 

No  more  striking  evidence  in  favor  of  the  parasitic  theory  in 
general,  and  of  the  specific  nature  of  the  separate  pathogenic 
germs  m  particular  can  be  brought  forward,  than  the  possession 
of  faxed  incubation  periods  by  many  infectious  and  contagious 
diseases.  The  quantity  of  the  virus  introduced  cannot  be  the 
cause  of  the  appearance  of  measles  on  from  the  9th  to  the  11th 


■'vm-rr-mj^m^'- 


26  LKCTUUES   ON   FKVEIJS. 

(Iny  after  the  infection,  or  of  the  iippoiiranco  of  scarlet  fever  on 
from  the  Itli  to  the  7th  ilay,  or  of  sniall-j)ox  on  from  the  lOtli  to 
the  i;]th  (lay.  3Ioro  probable  is  it  that  the  virus  needs  this 
time,  after  introduction  into  tlie  system,  to  develop  into  a  mor- 
bilic  agent.  And  in  the  further  progress  of  the  disease  it  is  also 
in-obablo  that  a  portion  of  the  energy  t)f  the  virus  consists  in  its 
I)assage  from  the  germ  state  or  particle  to  that  of  the  Hnished 
orgMuism. 

C'ohnheim  has  observed  that  anthrax  gives  no  outward  mani- 
festation of  its  presence   until  the  spores  have  developed  into 
bacilli,  and  that  in  trichiniasis.thi?  fever  and  the  myalgia  are  not 
noticeable  until   the  intestinal   trichinae  have  developed  from 
those  eaten  Avith  the  infected  meat,  and  from  these  a  new  gen- 
eration has  been  hatched.     Accoi'iling  to  this  view,  Tyndall  de- 
fines a  contiigious  disease  as   "  a  ccmflict  between  the  person 
smitten  by  it  and  a  specific  organism  Avliich  multiplies  at  his  ex- 
pense, appropriating  his  air  and  moisture,  disintegrating  V.is  tis- 
sues, or  poisoning  him  by  decompositions  incident  to  its  growth." 
In  this  connection  and  at  this  time,  it  will  not  be  necessary  to 
give    more  than  a  passing  notice  to  the  once  pojjular  but  now 
antiiiuateil  theory  of  spontaneous  generation— a  theory  which, 
though  born  with  Aristotle  and  mouldy  with  age,  never  has  and 
never  can  admit  of  experimental  proof.     Few  are  the  scientists 
who  to-day  believe  in  the  possibility  of  physical  conditions  ever 
operating  to  evolve  living  beings  from  absolutely  dead  organic 
matter.     That  life  cannot,  at  least  in  this  age,  arise  independ- 
ently of  pre-existing  life,  has  become  almost  a  truism.     The 
day  of  belief  in  vitiated  air,  foul  drains  and  foetid  odors  as  origi- 
nators of  disease  is    rapidly  passing  by.     ^\e  now  look  upon 
defective  drains  and  cesspools,  and  a  corrupt  atmosphere,  as 
potent  distributers  of  disease  only  Avlien   the  special  germ  of 
ejiidemic  disorder  is  ijresent.     And  notwithstanding  this,  sani- 
tary science  will  demand  as  much,  if  not  more,  attention  of  the 
physician  as  it  has  in  the  past.    For  though  bad  air  and  foul 
drains  cannot  create  disease  germs,  they  possess  the  power  of 
pushing  the  latter  into  virulent  energy  of  reproduction,   and 
thereby  promote  the  spread  of  disease,  suffering  and  death. 

"  Consider,"  says  Tyndall,  speaking  of  the  floating  dust  of 
the  air,  "  consider  the  woes  which  these  wafted  particles,  during 
historic  and  pre-historic  ages,  have  inflicted  on  mankind;  con- 


m.^'SS!^' 


CLASSIFICATION  OF  FEVEItS. 


27 


fover  on 
e  lOtli  to 
'ods  this 
to  )i  iiior- 

it  is  calso 
ists  in  its 
5  iinishoci 

iril  inani- 
iped  into 
ill  iiro  not 
peel  from 
new  gen- 
,-nclnll  tle- 
le  person 
at  his  ex- 
iig  '.is  tis- 
i  growth." 

cessary  to 
but  now 
ry  which, 
)r  has  and 
scientists 
tions  ever 
d  organic 
independ- 
ism.     The 
s  as  origi- 
look  npon 
sphere,  as 
1  germ  of 
this,  sani- 
tion  of  the 
ir  and  foul 
5  power  of 
ction,   and 
I  death, 
ng  dust  of 
les,  during 
ikind;  con- 


sider the  slaughter  wliich  has  hitlierto  followed  that  of  the  bat- 
tleiield,  when  those  bacterial  destroyers  are  hit  loose,  oftcMi  pro- 
ducing a  mortality  far  greater  than  that  of  battle  itself;  nUl  to 
tliis  the  other  conception  that  in  times  of  epidemic  disease  the 
self-same  floating  •  matter  has  mingled  with  it  the  special  germs 
wldch  produce  the  epidemic,  being  thus  enabled  to  sow  pesti- 
lence and  death  over  nations  and  continents.  Consider  all  tliis 
and  you  will  come  with  me  to  the  conclusion  that  all  the  havoc 
of  war  ten  times  multiplied  Avould  be  evanescent  if  compared 
with  the  ravages  due  to  atmospheric  dust.  This  preventible 
destruction  is  going  on  to-day,  and  it  has  been  permitted  t(i  go 
on  for  ages,  without  a  whisper  of  information  regai  ding  its  cause 
being  vouchsafed  to  a  suffering,  sentient  world.  We  have  been 
scoiirged  by  invisible  thongs,  attacked  from  impenetrable  am- 
buscades, and  it  is  only  to-day  that  the  light  of  science  is  being 
let  in  upon  the  murderous  dominion  of  our  foes.  From  the 
vantage  ground  already  won  Ave  look  forAvard  with  confident  hope 
to  the  triumph  of  medical  art  o\-er  scenes  of  misery  and  woe." 

Classification  of  Fevers.— LeaA-ing  the  general  causation  of 
this  group  of  diseases,  we  Avill  proceed  to  their  classification. 
And  though  a  classification  from  the  parasitic  standpoint  Avill 
be  the  classification  of  the  future,  the  want  of  a  better  knoAvl- 
edge  of  the  different  kinds  of  microphytes  forbids  our  formulat- 
ing it  to-day.  So,  following  the  classification  heretofore  ado{)ted 
in  our  lectures  in  this  college,  Ave  Avill  for  convenience  of  study, 
divide  the  fevers  into  the  foUoAving  classes:  Miasmatic  or  In- 
fectious, Miasmatic-Contagious  or  Contagious-Infectious,  and 
Contagious. 

Miasmatic,  Malarial  or  Infectious  Fevers  are  those  fevers 
which  are  caused  by  a  morbific  agent,  called  a  miasm  or  infec- 
tion, developed  exterior  to  the  physical  organism.  A  miasm  or 
infection  is  a  virus  developed  exterior  to  the  body,  usually  in 
connection  with  decomposing  organic  matter,  and  is  capable  of 
being  diffused  through  air  or  water.  Miasmatic  fevers  cannot 
be  conveyed  from  a  diseased  to  a  sound  individual,  but  may 
recur  frequently. 

Miasmatic-Contagious  or  Contagious-Infectious  Fevers, 

are  those  fevers  which  are  caused  by  a  morbific  agent  developed 
within  a  diseased  organism,  but  matured  and  reproduced  ex- 


i 


28 


LECTUnES  ON  FEVERS. 


terior  to  it  in  connection  with  decomposing  organic  matter. 
Miasmatic-Contagious  fevers  cannot  be  conveyed  directly  from 
the  sick  to  the  healthy,  but  only  by  the  excretions,  and  by  these 
but  feebly,  until  the  specific  germs  have  become  matured  and 
luxuriant  from  contact  with  decomposing  animal  and  vegetable 
matter  outside  the  diseased  organism. 

Contagious  Fevers  are  those  fevers  which  are  caused  by  a 
morbific  agent  developed,  matured  and  reproduced,  entirely 
within  a  diseased  physical  organism. 

A  contagion  is  a  virus  which  has  its  origin  only  in  a  living 
being,  and  is  capable  of  being  carried  from  one  individual  io 
another.  Contagious  fevers  can  be  conveyed  either  through 
the  atmosphere,  or  directly  from  the  sick  to  the  healthy;  and 
they  attack  the  organism  usually  but  once. 

Following  this  classification  we  will  arrange  the  fevers  as  fol- 
lows; 

FIRST  CLASS.— (J>/ms»m<ic.) 

I.— Intermittent  Fever.  IV.— Typho-Malarial  Fever. 

II.— Remittent  Fever.  V.— Dengue  Fever. 

III.— Pernicious  Fever.  TI.— Hay  Fever. 

SECOND  CLASH.— (Mittsmatic-Contagious.) 
I._Typhoid  Fever.  III.— Cerebro-spinal  Fever. 

II._yeIlow  Fever.  IV.— Influenza. 


THIRD  CLASS. - 

I.— Typhus  Fever. 
II.— Relapsing  Fever. 
III. — Small-pox  and  Varioloid, 
IV. — Varicella. 


-{Contagious.) 

v.— Miliary  Fever. 
VI.— Measles. 
VII.— German  Measles. 
VIII.— Scarlet  Fever. 


All  these  different  forms  of  febrile  affections  may  be  either 
epidemic  or  endemic,  but  they  are  seldom,  if  ever,  sporadic. 
They  are  said  to  be  epidemic,  when  they  attack  numerous  indi- 
viduals at  the"!  same  time  Jand  in  the  same  way;  endemic,  when 
they  appear  continuously  in  the  same  district,  and  sporadic  when 
they  attack  individuals  without  regard  to  time  and  place. 


natter. 
7  from 
7  these 
>d  and 
▼etable 

kI  by  a 
ntirely 


I  living 
dual  to 
hrough 
ly;  and 

1  aa  fol- 


Fever. 


Fever. 


es. 

)e  either 
poradic. 
)us  indi- 
ic,  when 
die  when 


LECTUKEIL 

Simple  Continued  Fever. 

I  shall  this  morning,  before  taking  up  the  history  of  miasmatic 
diseases,  direct  your  attention  to  a  fever  which  does  not  admit 
of  a  place  in  our  classification,  and  yet  is  frequently  met  with  in 
practice.    I  allude  to  Simple  Continued  Fever. 

Definition. — This  may  be  defined  to  be  a  non-specific  contin- 
ued fever,  which  runs  its  course  in  a  few  days,  and  terminates 
in  rapid  convalescence,  presenting  no  characteristic  lesion. 

Synonyms. — It  has  been  variously  known  and  described  as 
ephemeral  fever,  inflammatory  fever,  sun  fever,  and  heat  fever. 
Formerly  the  name  simple  continued  fever  was  used  as  a  cloak 
to  cover  the  transient  and  unmasked,  the  uncertain  and  the  abor- 
tive cases  of  fever,  that  might  occur  during  any  epidemic.  But 
to-day  it  is  narrowed  down,  so  as  to  include  only  those  cases  of 
continued  fever,  of  whatever  length,  that  are  of  non-specific  ori- 
gin, and  are  non-symptomatic. 

Etiology. — The  causes  of  this  fever  are  numerous.  Among 
them  we  may  mention  exposure  to  extremes  of  heat  and  cold, 
over-feeding,  emotional  excitement,  and  excessive  mental  or 
physical  fatigue.  It  occurs  more  frequently  during  the  sum- 
mer season,  and  prevails  more  among  children  than  adults. 

Clinical  History.— Simple  continued  fever  presents  no  pre- 
monitory symptoms.    The  onset  is  abrupt    The  fever  asserts 

(29) 


30 


LECTURES  ON   FEVEKS. 


its  prpsi^nco  liy  foelings  of  lassitudo  and  chilliness,  followed  by 
ft  sudden  rise  in  tonipemturo.  The  skin  becomes  hot,  tlie  pulse 
rapid,  and  the  thirst  excessive.  More  or  less  headache  and 
l)ain  in  the  lind)s  are  present  from  the  beginning  of  the  attack. 
The  bowels  are  generally  constijjated,  and  the  urine  is  dimin- 
ished in  quantity,  high-colored,  and  of  high  speciiic;  gravity. 
The  tongue  is  covered  with  a  white  coating,  and  tlie  a])petite  is 
either  lessened  or  lost.  Vomiting  is  rarely  present  unless  the 
attack  is  brought  on  liy  over-feeding. 

The  temjx'rature  rise  is  soon  at  its  height,  and  may  reach 
lOy  Fahr.,  or  oven  105  Fahr.,  in  a  few  hours.  Usually  the 
fever  is  of  short  duration,  and  convalescence  is  almost  always 
correspondingly  rapid. 

The  temperature  fall  may  be  either  sudden  or  gradual.  The 
fever  may  terminate  in  twenty-four  hours  with  a  copious  perspi- 
ration, by  a  critical  discharge  from  the  bowels,  or  by  a  large  de- 
posit of  urates  in  the  urine.  Or  it  may  take  from  two  to  ten 
days  to  run  its  course,  and  end  by  gradual  defervescence. 

Simple  continued  fever  presents  no  characteristic  eruption, 
though  herpes  may  be  said  to  occasionally  attend  it.  It  is  main- 
ly characterized  by  the  sudden  onset  of  the  fever,  and  the  rapid- 
ity with  which  the  maximum  temperature  is  reac'iied. 

Wilson,  following  Murchison,  describes  four  different  varieties 
of  this  form  of  fever: 

1.  The  ephemeral  variety,  which  is  ushered  in  suddenly 
with  chills,  or  alternate  chills  and  flushes,  followed  by  high 
fever,  intense  headache,  and  a  quick,  full  pulse.  The  skin  is  hot 
and  the  urine  scanty  and  high-colored.  The  tongue  is  coated 
white,  and  there  ui"e  anorexia  and  constipation.  Great  pain  in 
the  limbs,  as  from  a  bruise,  is  a  frequent  symptom.  An  attack 
reaches  its  acme  at  night,  and  usually  lasts  from  twelve  to  thirty- 
six  hours. 

2.  The  synochal  variety,  sometimes  called  and  described 
as  inflammatory  fever.  In  this  form  the  fever  runs  high,  and 
the  pulse  is  full  and  bounding.  The  skin  is  intensely  hot,  the 
headache  severe,  and  occasionally  accompanied  with  delirium. 
This  variety  runs  a  longer  course  than  does  the  ephemeral,  and 
is  apt  to  terminate  abruptly  with  copious  perspiration. 

3.  The  ardetd  eontinued  fever  of  the  tropics,  which  oc- 
•curs  mostly  during  hot,  dry  weather,  among  non-acclimated. 


.\STHEXK!   SIMPLE   FKVER. 


31 


plethoric,  yonng  individuals.  Au  attack  is  gonprally  ushered 
in  with  a  chill,  or  nausea  and  vomiting,  followed  by  a  high  fever, 
quick  full  pulso,  hot  skin,  intense  headache,  and  great  restless- 
ness. Active  delirium  is  apt  to  apj)ear  about  the  fourth  or  fifth 
day,  and  may  be  followed  by  unconsciousness  or  at  times  coma. 
Convalescence,  marked  by  a  copious  persjuration  and  an  in- 
creased flow  of  urine,  may  set  in  between  the  sixth  and  ninth 
days,  or  death  may  take  place  from  a  continuance  of  the  coma, 
or  from  sudden  collapse  following  the  subsidence  of  the  fever. 

4.  Afttlimic  simple  fcvtn'.  This  form  tends  to  follow  excess- 
ive l)odily  or  mental  fatigue,  and  lasts  from  two  to  three 
weeks.  The  fever  is  less  marked,  and  the  temperature  rise  less 
sudden  than  in  the  other  varieties.  The  pulse  is  generally  quick 
but  feeble.  The  tongue  is  ajjt  to  be  somewhat  coated,  and  the 
bowels  constipated.  At  night  the  sleep  is  more  or  less  dis- 
turbed, and  is  frequently  followed  by  a  slight  headache  during 
the  waking  hours.  And  although  the  strength  of  the  patient 
gradually  fails  as  the  fever  runs  its  course,  asthenic  simple 
fever  seldom,  if  ever,  terminates  fatally. 

The  Duration.— The  ephemeral  variety,  which  occurs  most- 
ly in  children,  often  runs  its  course  in  a  few  hours.  Mild  forms 
of  simple  continued  fever  have  in  temperate  climates  an  average 
duration  of  from  three  to  six  days.  And  the  asthenic  variety, 
which  is  characterized  by  less  active  fever,  may  continue  two  or 
three  weeks. 

ANALYSIS  OF  CHART. 

The  Temperature.— A  sudden  rise  of  temperature  to  103  ° 
Fahr.,  or  105  o  Fahr.,  is,  as  has  been  suggested,  the  characteris- 
tic symptom  of  simple  continued  fever.  In  mild  cases  the  fall 
diiring  convalescence,  though  sudden,  is  never  so  rapid  as  is  the 
rise,  during  the  onset  of  the  fever.  Severe  cases,  or  those  of 
longer  duration,  are  marked  by  a  more  gradual  defervescence. 

The  Pulse.— The  pulse  is  quick,  full,  and  bounding,  in  all 
varieties  except  the  asthenic,  in  which  it  is  quick  and  feeble. 

The  Nervous  System.— Chills  and  rigors,  followed  by  head- 
ache, usually  usher  in  the  initial  stage.  The  headache  is  acute, 
and  may  be  followed  by  delirium.  In  the  ardent  variety  the 
delirium  may  lead  to  stupor,  coma  and  death. 

The  Alimentary  Tract.— The  appetite  is  generally  lost,  and 


^ 


LECTUKES  ON  FEVERS. 


t 


U 


h 


y  * 


ii 


CHART  I.— Simple  Ccmiinncd  Fever. 

Forms : 

Ephemeral, 

Intlammatory. 

Ardent, 

Asthenic. 

Duration: 

2  days, 

3  to  5  or  10  days. 

7  to  10  days. 

14  to  21  days. 

Causes: 

Exposure,  fatigue  and  over-feeding. 

Initial 
Symptoms: 

Chills  and  rigors. 

Chill,  or  nausea 
and  vomiting. 

Lassitude  and 
anorexia. 

Tempera- 
ture: 

Sudden  rise  to  103"  Fahr.  or  105^'  Fahr. 

99"  to  102". 

Pulse: 

Quick  and  full. 

Full  and 
b  o  u  n  d  i  n  g. 

Freciuent  and 
full. 

Fremient  and 
feeble. 

Head: 

Intense 
headache. 

Sharn 
headaclie. 

Iiitc'iisvhcuducho. 
cluliriuin,  coniii, 

Slight 
headache. 

Tongue: 

White  coating, 

Slightly 
furred. 

Stomach: 

Thirst  and  loss  of  appetite. 

Nausea  and 
vomiting. 

Anorexia. 

Intestinal 
Canal: 

Constipation. 

Urine: 

Scanty,  high  colored,  copious  deposit  of  urates 
during  convalescence. 

Extremities 

Pains  as  from  a  bruise. 

Skin: 

Intensely  hot,  copious  perspiration  during  convalescence. 

Prognosis: 

Favorable, 

Guarded, 

Favorable. 

-.v-r: 


-;a{m^-,:r- 


jjami 


DIAGNOSIS. 


89 


thirst  is  quite  mnrketl.    Vomiting  is  rarely  present.    The  bow- 
eld  are  usually  constipated. 

Fio.  7. 


1 

DAY 

1 

o 

,  1 

M 

E 

Jt 

E 

:\t 

E 

i04°-r 

A 

/ 

\ 

102°- 

/ 

\ 

O  _ 

101- 

/ 

0_ 

100 

1 

V 

^ 

99°i 

/ 

\ 

/ 

V 

-    i 
03°  ~ 

V 

Temperature  in  Simple  Continued  Fever  (Wnnderlich.) 

The  Urine. — The  urine  is  characteristically  "febrile"  and  is 
diminished  in  quantity.  It  contains  a  large  quantity  of  urea, 
and  is  of  high  specific  gravity,  varying  during  the  fever  from 
1030  to  1035.  During  defervescence  the  quantity  of  urine  rap- 
idly increases,  and  a  copious  deposit  of  urates  takes  place. 

The  Cutaneous  Surface. — The  skin  is  hot  and  dry,  and  occa- 
sionally erythematous.  Herpes  is  sometimes  jiresent  upon  the 
lips  and  nose. 

Diagnosis. — The  diagnosis,  though  at  times  obscure,  may  as 
a  rule  be  outlined  with  a  certain  degree  of  accuracy.  When 
differentiating  it  from  other  fevers  it  is  well  to  remember  that 
simple  continued  fever  may  occur  sporadically,  at  times  when 
no  epidemic  is  prevailing.  The  majority  of  the  fevers  are  either 
epidemic  or  endemic.  Simple  continued  fever  is  of tener  caused 
by  over-exertion,  over-feeding,  or  over-heating.  It  begins  ab- 
ruptly, and*s  marked  by  a  rapid  temperature  rise.  This,  along 
with  the  absence  of  an  eruption,  and  of  abdominal  symi)toms, 


i 


:  \ 


!    > 


84 


i-EcniiEH  ON  rr.vKiis. 


phouhl  1)0  HufliciiMit  to  .litT.M-iMitinto  it  from  typlioitl  fovor.     And 

thofm'cloinfroiu  j''»i"'li^'''' f'"'"  I'"'""  "'  *''*'  J"'"^"' "'"^  ^'■'''" 
oiil.ir^^cn.oiit  of  tlu'  liver  nml  npl.H'n,  iih  well  iih  tlio  ah^'iico  of 
si.iiilld  in  tl.o.l.l.Mul,  oiiyht  to  ainbroiitinto  it  from  rolapHing  or 
hpirillnm  fovor. 

FKi.a 


'l\mperut»re  iu    Simple    Contimie.l   l-ever:    more   t:rudu«l   dclei- - csceucc 

(Wunderlicli.) 

Prognosis.— In  temperate  climates  the  prognosis  is  generally 
favorable,  as  the  disease  tends  to  recovery.  In  tropical  regions, 
however,  the  prognosis  is  more  grave,  and  death  is  not  an  nn- 
comraon  occurrence. 

Treatment.— The  diet  should  be  light  and  non-stimulating  for 
the  milder  forms,  except  in  the  latter  stage  of  the  asthenic,  when 
a  supporting  diet  is  necessary.  Milk,  blancmange,  and  light 
broths  prove  all-suflicient.  In  long  lasting  cases,  koumyss,  wine- 
whey  and  egg-nog  may  be  added.  Water  should  form  the  prin- 
cipal beverage.  When  fever  is  high,  l)roken  ice  on  the  tongue 
is  very  grateful.  Cold  water  sponging  adds  greatly  to  the  comfort 
of  the  patient,  and  in  severe  cases  the  pack  may  be  resorted  to 
with  benefit. 


,.iicii,i!!ijjj...  '-■»,eiia"-g:-j^.-J 


MALAIIIAL   FEVKUS. 


:)5 


voY.     And 
ami  fniin 

lllSl'lU't'  tif 

livi)Hing  i)r 


n 

-  — 

M 

.K     1 

\  • 

S^ 

^ 

t. 

ilcl'er .  I'scfui't' 

is  generally 
cal  regions, 
not  an  un- 


lulating  for 
henic,  when 
e,  and  light 
imyss,  wine- 
rm  the  prin- 
1  the  tongue 
the  comfort 
resorted  to 


Aroillte.  — The  therapeutics  of  simple  tH)utinueil  fovor  may  Im; 
expri'Hisetl  in  f«'w  words.  In  the  epliemeral  variety  we  mod  no 
iither  remedy  tlian  aconite.  And  in  the  ardent  variety,  accord- 
ing to  our  Kast  India  confreres,  it  is  a  most  potent  aid.  It  is 
spt'cially  iudicuted  wlien  the  pulse  is  very  quick,  hard  and 
sharp. 

Caiiiphur  may  be  useful  during  tiio  first  hours  of  the  fever, 
especially  when  tiie  attack  is  caused  by  exposure  to  sudden 
changes  of  temperature. 

(jelsciiiiiini  is  indicated  when  taking  cold  is  the  cause,  and 
there  is  great  nervous  restlessness,  witli  a  quick,  largo,  soft  pulse. 

Yeriitruiii  vlr.  is  adapted  to  all  forms,  with  the  exception  of 
the  asthenic.  It  is  particularly  beneficial  when  there  is  u  hard, 
full,  quick,  bounding,  incomjjressible  pulse,  with  headache,  dim- 
ness of  vision,  nausea,  and  extreme  restlessness. 

Bryonia  is  called  for  when  the  shooting  jjains  in  the  limbs 
prove  distressing  to  the  patient,  and  especially  when  accompa- 
nied by  n  heavy,  stupefying  lieadache,  aggravated  by  motion. 
The  bryonia  fever  is  mostly  caused  by  cold  or  error  in  diet,  or 
comes  on  during  hot  summer  weather.  It  seldom  runs  as  high 
as  does  the  aconite  or  veratrum  fever.  The  tongue  may  be 
coated  yellow  or  thinly  covered  with  mucus,  and  the  taste  is  flat 
and  pasty. 

Arsenicum  alb.  will  be  of  use  in  prolonged  cases,  and  when 
there  is  great  prostration. 

Belladonna  may  be  occasionally  indicated  for  the  cerebral 
symptoms. 

For  further  therapeutic  indications  I  will  refer  you  to  the 
treatment  of  intermittent  and  typho-malarial  fevers. 


Malarial  Fevers. 

With  this  digression  we  will  proceed  to  the  consideration 
of  the  malarial  or  viiasmaiic  fevers— the  first  in  order  of 
classification.  The  many  varieties  of  this  class  of  fevers  have 
a  common  origin   in  a  morbific  agent,  which  has,  l>y   gen- 


If  ( 


:u; 


LlXTUllEH  ON    FKVEIIH. 


oral  consent,  rccoivoil  tho  nnmo  of  miasm.  Thoy  prowrnt  many 
BymptoniB  luul  cotulitioim  which  sorvo  tt>  outline  tho  cIiihh, 
luul  yet  uro  iittt'ndml  by  phtMioinoim  8o  widely  different  in  chiir- 
nctor  iiH  to  nccoHHitiito  their  beinj?  reRiirded  m  diHtiuct  dirioiiHeH, 
The  Hoverity  and  typo  of  fever  »ire  determined,  other  thingH  be- 
ing ecpial,  by  tho  (uuount  of  miasm  operating  at  any  given  time, 
and  tho  proaonco  or  abHenco  of  conditionH  favoring  its  dovelop- 
mont.  Tho  more  intenHO  and  concentrated  tho  malarial  poison, 
and  tho  more  i)rolonged  tiio  exposure  to  its  influence,  tho  more 
rapid  will  bo  tlio  development,  and  tho  greater  tho  extent  of  the 
morbid  processes.  Arranged  in  a  progrossivo  scale,  marked  by 
tho  (piantity  and  intensity  of  the  miasm,  wo  may  begin  with  tho 
qujirtan  intermittent,  and  ascend  to  tho  tertian;  go  still  higher 
to  tho  doul)lo  tertian  and  tho  remittent,  and  at  last  reach  tho  per- 
nicious. Tho  more  severe  tyi)©s  aro  apt  to  bo  encountered  in  the 
tropics,  and  tho  lighter  prevail  tho  farther  we  recede  from  the 
equator. 

Malarial  diseases  are  usually  endemic  in  character.  At  times 
thoy  are  epidemic,  and  when  so  prevalent,  appear  to  stand  in  some 
hitherto  inexplicable  relation  to  epiilemics  of  other  diseases. 
Accordii:g  to  Hertz  the  first  recorded  malarial  epidemic  pre- 
vailed  in  1558,  and  spread  over  the  whole  of  Europe.  It  was 
preceded  by  the  influenza  epidemic  of  1557,  and  followed  by  tho 
plague  from  1559  to  1503.  Tho  second  malarial  pandemic  occur- 
red in  1G78  and  1G79,  and  was  followed  by  the  plague,  which 
lasted  for  three  years.  The  third  epidemic  appeared  during  the 
four  years  following  1718,  and  was  succeeded  by  a  general  out- 
break of  typhoid  fever.  The  fourth  prevailed  from  1807  to  1812. 
It  was  preceded  by  influenza  and  followed  by  typhoid  fever. 
And  the  epidemics  of  1824  and  1845  were  each  the  forerunner  of 
a  typhoid  epidemic. 

Influenza  and  malarial  diseases  seldom  prevail  simultaneously. 
The  same  may  be  said,  though  in  a  less  general  sense,  of  typhoid 
fever  and  malaria.  On  the  other  hand,  epidemics  and  endemics 
of  remittent  and  t^  hus  are  -frequently  met  with  at  the  same 
time.  Cholera  and  malaria  often  flourish  side  by  side,  while 
intermittent  fever  and  dysentery  are  well-known  associates. 
Miliary  tuberculosis  too,  frequently  exists  alongside  of  int«r- 
,  mittent  fever  in  malarial  districts.  The  presence  of  malaria  is 
now  generally  believed  to  favor  and  predispose  to  phthisical  de- 


I 


,:;yTy„>,T:^Tiau; 


.fe-«f» 


GEoaiiAnncAL  limits. 


8T 


DHont  many 

tlu>     I'luHH, 

mt  in  chiir- 
ct  (litteiiHOH. 
•  thingH  bt>- 
givon  timo, 
.ts  ilevelop- 
riul  pDiHon, 
B,  the  more 
:tent  of  the 
miirked  by 
(in  with  the 
still  higher 
iich  the  por- 
torod  in  the 
le  from  the 

•.  At  times 
and  in  some 
er  diHenses. 
tidemic  pre- 
tpe.  It  wns 
owed  by  the 
[omic  occur- 
xgue,  which 
li  daring  the 
general  out- 
1807  to  1812. 
)hoid  fever, 
srerunner  of 

lultaneously. 
e,  of  typhoid 
nd  endemics 
at  the  same 
'  side,  while 
a  associates, 
ide  of  inter- 
3f  malaria  is 
)hthisical  de- 


vflitpiucnt.  And  it  in  a  cliBi^  fact  that  in  oxtonHivo  endcmii-s 
of  iiittTiuittciit  I't'vtT,  otlicr  tlisieaMeH  art*  apt  to  present  the  typ- 
ical foaturt'H,  (*xa(>t>rl)Hti(>ii  and  rcmiMHioui. 

(il(>Oi;ra|»liical  LiiiiitN.  ^'ilaria  may  prevail  anywliprw  be- 
tw»'(Mi  <;.*{  =  nortli  latitude  mui  .7  °  Houth  latitiulo,  but  Ih  moro  in- 
ttMiHO  the  nearer  the  appiuacli  to  the  ecpiator.  It  is  seldom  gen- 
t  rated  above  an  elevation  of  1,()0()  foot  above  sea  level.  To  this 
rule,  Imwover,  tlnTo  aroHxceptionri.  For  malaria  hartboen  found 
in  I'eru,  at  an  altitude  i*t  1(>,(MX)  feet,  and  in  the  plateaus  of  the 
ryreiiet>s  at  5,000  feet,  as  well  ns  in  lesser  elevations.  Italy  is 
iinddubtedly  the  most  malarious  of  all  European  oountrios.  The 
Pontine  marshes  are  jiroverbial  as  being  vast  hotbeds  of  malaria. 
In  Africa  the  »nost  virulent  forms  of  malarial  diseasPH  appear  tm 
thr>  western  ccast  and  along  the  banks  of  the  Niger  and  Senegal 
rivers.  The  d'jltn  of  the  (langes  is  the  most  malarious  region 
in  all  Asia.  And  on  this  continent  the  Gulf  states,  the  western 
coast  of  Peru,  and  tJio  interior  of  Brazil  furnish  the  most  malig- 
nant forms  of  malarial  diseases. 

Marshes  are  especially  favorable  to  the  development  of  mala- 
ria, and  yet  all  marshes  are  not  malaria  i)roducing.  Such  as 
have  a  clay  or  limestone  l)ottoni  develop  the  poison  more  read- 
ily than  those  possessing  a  sandy  substratum.  Dried  up  marshes 
develop  it  more  rapidly  than  the  submerged.  Heavy  rains 
cover  up  the  marshes,  and,  although  they  favor  a  luxurious  veg- 
etation, protect  them  from  the  intiuence  oi  the  sun's  rays.  After 
the  rains  have  ceased  and  the  marshes  begin  to  dry  up,  the  heat 
of  the  sun  causes  vegetable  decomposition  to  take  place,  and  im- 
mediately all  the  conditions  favoraljle  to  the  development  of 
malaria  are  presented.  Hence  malarial  diseases  prevail  more 
extensively  during  hot  weather  following  heavy  rains,  than  at 
any  other  time.  Some  marshes  are  always  fecund  with  malaria. 
Witness  the  Pontine  marshes  which  have  been  malarial  for  over 
2.000  years.  On  the  other  hand  there  are  extensive  swampy- 
regions  in  hot  climates  tliat  are  entirely  free  from  malarial 
fevers.  Among  these  may  be  mentioned  the  warm  swamp  re- 
gions of  the  Australian  coast,  and  the  shores  of  the  lake  of  Tes- 
cudo,  in  Mexico.  Low  lands  that  are  exposed  to  annual  over- 
flow, such  as  are  found  along  the  southern  shores  of  the  Missis- 
sippi, are  as  fruitful  of  malaria  as  the  swampy  regions.  Salt 
water  marshes  are  as  a  rule  free  from  malaria.    But  a  mixture 


')  -< 


11 


s. 


as 


LECTUliKS   O.N    I'EVEliiS. 


of  salt  and  fresh  water,  as  on  the  NeAv  Jersey  flats,  is  specially 
favorable  to  its  development.  Malarial  soils,  though  oftenest 
found  in  swampy  regions,  arc  frequently  discovered  in  localities 
which  are  not,  and  never  have  been,  swampy.  In  new  and  unset- 
tled districts  the  upheaval  of  the  alluvial  soils  favors  the  devf  1- 
opment  of  malaria. 

Edwards  rationally  explains  this  by  saying  that  "all  land — 
all  soil  that  has  never  been  before  worked, — is  i)articularly  rich 
in  organic  matter.  The  leaves  from  the  trees  have  for  centuries 
been  dying,  decomposing  and  yielding  their  organic  constituents 
to  this  earth.  The  bu'ds  and  wild  animals  which,  from  the  be- 
ginning of  time,  have  roamed  over  this  virgin  land,  have  depos- 
ited tbeir  organic  excrement  upon  it.  The  winds  have  wafted 
organic  material  from  far  ofi'  cities  to  it;  while  countless  myriads 
of  animals  have  died  and  decomposed  on  this  land,  yielding  up 
their  comi)onent  parts  to  it.  The  rains  and  snows  of  centuries 
have  washed  all  this  organic  material  into  the  earth,  until  this 
land  fairly  teems  with  organic  wealth.  Like  the  untrodden  prai- 
ries of  our  western  country  it  is  black  with  organic  richness. 
Some  little  of  this  material  is  utilized  in  giving  nourishment  to  the 
grass  and  trees  which  grow  on  this  soil.  Still,  but  a  very  email 
proportion  of  this  organic  matter  is  thus  consumed,  and  what 
little  is  used  is  returned  a  hundred-fold  in  the  manner  indicated 
above,  until  the  sub-soil  of  this  region  is  fairly  reeking  with  or- 
ganic elements  not  exposed  to  the  sun,  while  that  very  near  the 
surface  is  consumed  by  the  grass  and  trees.  This  soil  contains 
moisture.  Mnn  and  civilization  come  along;  the  plough  turns 
up  this  land;  this  enormous  accumulation  of  organic  matter  is 
exposed  to  the  sun. 

"  What  haA^e  we?  Organic  matter,  heat  and  moisture."  The 
three  conditions  which  Ave  Avill  soon  find  are  the  most  favorable 
to  the  developments  of  malaria.  At  this  date  malarial  diseases 
are  spreading  eastward  and  northward  in  the  New  England  states. 
Just  why  this  should  be  so  Ave  are  unable  to  say.  The  state 
authorities  are  busily  engaged  trying  to  solve  the  problem. 

The  Nature  of  Miasm. — Up  to  the  present  time  but  little 
is  knoAvn  of  the  exact  nature  of  malarial  poison.  Many  theories 
have  been  advanced  concerning  it,  since  the  dawning  of  the 
present  century.  Some  of  the  older  obserA-ers  believed  that  it 
was  the  result  of  the  decomposition  of  vegetable  organisms,  ."ud 


'y^^r- 


BACILLUS  MALAIUJL. 


89 


lats,  is  specially 
though  oftenest 
n-ed  in  localities 
I  new  and  unset- 
Euvors  the  dev^  1- 

that  "all  iand- 
particularly  rich 
ave  for  centuries 
anic  constituents 
ch,  from  the  be- 
aud,  have  depos- 
uds  have  wafted 
ountloss  myriads 
md,  yielding  up 
lows  of  centuries 

earth,  until  this 
3  untrodden  jjrai- 
jrganic  richness, 
ourishmentto  the 

but  a  very  email 
sumed,  and  what 
manner  indicated 
'  reeking  with  or- 
lat  very  near  the 
'his  soil  contains 
the  plough  turns 
)rganic  matter  is 

moisture."  The 
le  most  favorable 
malarial  diseases 
;w  England  states, 
say.  The  state 
;he  problem. 

it  time  but  little 
1.  Many  theories 
dawning  of  the 
3  believed  that  it 
le  organisms,  ."ud 


existed  in  a  gaseous  form.  Others  attributed  it  to  subterranean 
exhalations.  A  few  declared  it  to  be  a  specitie  poison  having 
no  tangible  chemical  or  microscopical  constituents.  Some  be- 
lieved it  to  be  of  a  vegetable  nature,  while  others  com  tuded  witli 
Arraand,  that  the  tiierino  and  electro-hygrometric  phenomena 
of  the  atmosphere  constituted  the  remote  causes  of  fever.  These 
conjectures  all  remain  unproven,  and  we  are  as  yet  in  doubt 
concerning  the  nature  and  working  of  tlie  malarial  poison. 

The  theory  that  is  now  attracting  the  most  attention,  and 
which  thus  far  appears  the  most  rational,  is  that  which  attrib- 
utes all  malarial  diseases  to  the  presence  and  germination  of  a 
special  fungus,  the  bacillus  malariir  (Fig.  J:),  in  the  blood.  The 
recent  experiments  of  Klebs  and  Tomnmssi-Crudeli  of  Home, 
following  those  of  Scoda,  Balestra,  Salisbury,  and  Hannon,  have 
done  much  to  turn  the  tide  of  professional  opinion  in  favor  of 
the  parasitic  theory.  The  former  experimenters  claim  to  have 
discx>vered  to  a  certainty  the  presence  of  the  bacillus  mjdariiu 
in  the  soil  and  atmosphere  of  malarial  districts,  and  also  in  the 
blood  of  malarial  fever  patients.  The  "Medical  Times  and 
Gazette"  in  publishing  an  abstract  of  their  report  says:  They 
first  succeeded  in  i^roducing  the  symptoms  of  malarial  poisoning 
in  animals  l)y  injection  of  watery  extracts  from  the  marshy  soil. 
They  then  proceeded,  by  the  process  called  "  fractional  cultiva- 
tion," to  isolate  the  active  material,  that  is  the  true  generator 
of  the  disease,  supposed  to  be  a  living  organism.  Lastly  they 
isolated  the  organisms  by  filtration,  and  comparing  the  results 
obtained  in  injections  of  the  filtrate  with  those  x)roduced  by  the 
residue  containing  the  organisms,  they  proved  that  the  poison  of 
malaria  resides  in  these.  The  fungi  obtained  appeared  as  small 
rods  of  0.002  to  0.007  iiillimeter  in  length,  growing  into  long 
twisted  threads.  The  fuigus  is  markedly  aerobiotic.  If  air  is 
excluded,  it  dies  out.  The  injection  of  these  fungi,  true  bacilli 
malarife,  into  the  healthy  animals  always  gives  rise  to  symptoms 
of  intermittent  fever,  with  enlargement  of  the  spleen,  etc.  Later, 
Cuboni  and  Marchiafava  at  Rome,  have  been  able  to  demonstrate 
spores  and  bacilli  in  the  spleen,  the  marrow,  and  blood  of  three 
persons  who  died  of  pernicious  fever,  showing  the  same  charac- 
ters as  those  observed  by  Klebs  and  Crudeli.  Dr.  Sternberg's 
exi)eriraents  with  swamp  mud  taken  .!rom  the  suburbs  of  New 
Orleans  fully  corroborate  those  of  the  Italian  physicians. 


^>i 


*t  t 


40 


LECTUIlKfS  OX   FEVEllS. 


; ! 


i 


Important  observntioTis  have  still  more  recently  been  made  by 
Lavcrau  and  llicliard  in  Franco.  The  former  noticed  u  peculiar, 
though  differently  formed,  organism  i)ossessing  very  remarkable 
cliaracters,  invariably  present  iu  the  blood  of  malarial  fever 
putients;  wliilo  the  latter  found  the  special  habitat  of  the 
l)arasito  to  bo  the  red  corpuscles  of  the  blood.  Richard's  obser- 
vatiiUis  on  the  nfe  history  t)f  the  organism  are  thus  reported: 
"  During  the  attick  of  fever  many  blood  globiiles  are  seen 
which  po.-  CSS  a  small,  perfectly  round  spot,  but  they  have  other- 
wise the  normal  appearance  and  possess  the  normal  elasticity. 
In  other  corj)US!  les  the  evolution  of  the  parasite  is  further 
advanced;  the  l^ar  si)ot  is  enlarged  and  is  encircled  by  small 
black  granules,  while  around  it  the  haemoglobin,  recognizable  l)y 
its  gieeuish-yollow  tint,  forms  a  ring  which  becomes  ruirrower  as 
the  i)arasito  increases  in  size.  Ultimately  this  substance  of  the 
corpuscle  is  reduced  to  a  narrow,  dect)lorized  zt)ne,  from  which 
the  hitmoglobin  has  disappeared.  The  appearance  is  then  that 
of  a  circular  element,  having  nearly  the  dimensions  of  n  red 
blood  globule,  and  containing  an  elegant  '  collarette '  of  l)lack 
granulations,  which  is  in  effect  the  organism  arrived  at  maturity. 
The  parasite  then  pierces  the  membrane  which  contains  it,  and 
escapes  into  the  blood  plasma.  In  the  ultimate  condition  of 
maliy  of  the  infected  corjiuscles  the  pigmentary  collarette  is 
absent,  and  there  is  merely  a  greyish  mass,  containing  a  feAV 
black  granulations,  Avhich  have  been  noted  by  Kelsch,  and  some 
other  observers.  These  ijigment-granules  become  free,  and 
rapidly  broken  up  by  the  leucocytes,  which  become  impregnated 
with  them.  Hence  the  melanotic  leucocyte,  which  has  often  been 
observed  in  malaria  is,  so  to  speak,  only  an  epi-phenomenon  of 
the  palustral  process,  the  in'imordial  and  essential  change  being 
that  in  'he  red  corpuscles."  But  it  is  impossible  here  to  enter 
into  a  more  lengthy  consideration  of  the  facts  and  arguments  bj* 
which  this  parasitic  view  has  heou  supported.  Suffice  it  to  say 
that  from  the  evidence  already  at  our  command  the  bacteria 
theory  may  be  considered  as  placed  on  something  like  a  sub- 
stantial basis. 

The  Laws  of  Malaria. — In  all  malarial  localities,  three  imi)or- 
tant  factors  are  invariably  necessary  for  the  multiplication  of 
the  parasi*.e,  and  development  of  the  morbific  agent: 

1.  A  cartuiu  amount  of  vegetable  matter. 


IMMUNITY   FIJOM   MALAIUA. 


41 


n  maile  by 
n,  poculifir, 
emnrkablo 
irial  fever 
lit  of  the 
rd's  obser- 
reported: 
are  seen 
mve  other- 
elasticity, 
is  further 
'  by  snmll 
nizable  l)y 
arrower  as 
lice  of  the 
om  which 
then  that 
of  n  red 
!'  of  lihick 
t  maturity, 
iiinsit,  and 
udition  of 
lUarette  is 
ing  a  few 
and  some 
free,  and 
ipreguated 
often  been 
omenon  of 
mge  being 
re  to  enter 
uments  by 
e  it  to  say 
le  bactei'ia 
ike  a  sub- 


ree  impor- 
lication  of 


2.  A  certain  amount  of  moisture. 

y.  A  certain  average  degree  of  temperature. 

The  vegetable  matter  and  the  moisture  must  be  found  either 
on  the  suriace,  or  in  the  substance  of  the  soil.  And  the  averaire 
temperature  for  the  twenty-four  hours  must  not  fall  below  58° 
lahr.  A  prolific  germination,  and  consequent  rapid  increase 
of  malaria,  will  not  take  place  unless  the  average  daily  tempera- 
ture ranges  as  high  as  GS'  Fahr. 

Malaria  may  find  entrance  into  the  human  organism  in  either 
of  two  ways: 

1.  By  the  respired  air. 

2.  By  the  intestinal  tract,  with  food  or  water. 

•x  ^!r  i^itroduced  into  the  body,  it  has  the  power  to  reproduce 
Itself.  The  length  of  time  that  elapses  between  the  introduction 
ot  the  morbific  agent  and  the  outbreak  of  the  malarial  attack 
varies  from  six  to  twenty  days.  This  period  is  called  the  stage 
of  incubation,  and  has  an  average  length  of  fourteen  days. 

No  race  or  nationality  enjoys  immunity  from   malaria     But 
according  to  statistic^,  the  blacks  are  less  susceptible  than  the 
whites.     All  periods  of  life  from  infancy  to  old  age  are  liable 
to  Its   attacks.     In  children  under  five  years  it  commonly  as- 
sumes the  form  of  intermittent  bowel  troubles.     In  youth,  inter- 
mittent and  remittent  fevers  are  the  most  prevalent.     In  adult 
life,  malaria  may  appear  in  all  its  forms.     And  in  old  age,  the 
attacks  though  less  common,  are  apt  to  take  on  the   pernic'ious 
type.     Women  are  more  susceptible  than  men.     The  masked 
forms  of  intermittents  occur  more  among  'he  former,  while  the 
severer  forms  of  malarial  diseases  are  of tener  met  with  among  the 
hvtter.     Women  are  oftenest  attacked  at  the  time  of  menstrua-  ' 
tion,  but  are  said  to  enjoy  immunity  during  the  last  months  of 
pregnancy.     Idiosyncrasies  of  constitution  render  some  less  lia- 
ble than  others  to  its  influence.     The  weak  and  the  ana>mic  are 
easy  victims;  and   an  organism  once  invaded  is  thereby  ren- 
dered more  liable  to  subsequent  attacks.      It  is   very   doubtful 
whether  an  organism  which  has  once  been  thoroughly  charged 
with  malaria,  can  ever  become  entirely  free  from  its  influence. 
A  certain  degree  of  tolerance  of  malaria— called  by  some  ac- 
climation—may come  from  long  residence  in  a  malarial  district 
This  tolerance  must  not  however  be  construed  an  exemption 
from  Its  influence.    And  although  it  is  the  new  comers  to  a  ma- 


1 


S 


43  LF.CTUUEB  ON   FEVKH8. 

larial  district  who  suffer  the  most  from  the  acute  raanifestntioiis, 
yet  the  oKler  residents  nro  apt  to  enjoy  less  robust  health  in 
consequence  of  some  chronic  malarial  affection.  Should  one  of 
the  latter,  old  and  ajjparently  acclimated  settlers,  bo  taken  sick 
with  any  active  form  of  disease — pneumonia  for  example-  hri 
would  be  almost  sure  to  succumb,  owing  to  the  surcharge  of  the 
system  with  malarial  poison,  when  under  other  circumstances  he 
would  in  all  probability  have  recovered. 

Malaria  is  peculiarly  endemic,  and  seldom  wanders  far  from 
its  native  soil.  It  may  however  be  carried  down  rivers  from 
malaria-generating  to  non-generating  regie ms;  and  it  may  also 
be  carried  by  the  wind  from  malaria  producing  to  non-malarial 
districts.  From  four  to  five  miles  is  the  greatest  distance  it 
has  been  known  to  be  transmitted  by  the  wind.  It  may  be 
carried  by  the  latter  up  along  the  sides  of  mouutaius  to  an  eleva- 
tion of  from  500  to  1,000  feet. 

Conditions  Favorable  to  the  Development  of  Malaria.— 

The  three  conditions  necessary  to  the  development  of  miasm 
are: 

1.  A  luxurious  vegetation,  with  partial  decomposition. 

2.  A  temperature  above  5H''  Fahr.  The  higher  the  temper- 
ature, the  more  virulent  the  miasm. 

3.  Moisture  and  atmospheric  air. 

As  aiding  or  supplying  these  conditions,  we  will  mention  the 
following: 

1.  Marshes,  swamp  lands  and  damp  lx>ttom  lands.  These  are 
especially  active  after  heavy  rains,  when  they  are  drying  up,  or 
are  simply  covered  with  a  thin  sheet  of  water. 

2.  A  mixture  of  salt  and  fresh  water  marshes  furnishes  the 
most  favorable  conditions  for  the  development  of  malaria. 

3.  Railroad  excavations,  and  the  cultivation  of  new  lands^ 
favor  the  generation  of  miasm  by  bringing  decomposed  vege- 
table matters  to  the  surface,  and  by  exposing  the  new  soil  to  the 
heat  of  the  sun  and  moisture. 

The  excavations  necessary  for  the  laying  of  the  cable  track  of 
the  south  side  street  railway,  and  for  the  putting  down  of  sew- 
ers in  this  city,  are  at  the  present  time  causing  the  generation  of 
malaria,  as  evidenced  by  the  increase  of  malarial  diseases  along 
the  lines  of  excavation. 

4.  Hertz  speaks  of  the  favorable  conditions  for  the  develop- 


DEVELOrMENT  OF  MALAEIA. 


4:1 


estntiiiiiK, 
lenlth  in 
1(1  oue  of 
(iken  sick 
mple-  I:r^ 
'ge  of  tiio 
tauces  he      • 

far  from 
ers  from 

mny  also 
i-mnlarial 
istance  it 
t  may  be 
» au  eleva- 

alaria.— 

of  miasm 

>n. 

e  temper- 


ention  the 

These  are 
ug  up,  or 

nishes  the 
aria. 

lew  lands, 
osed  vege- 
soil  to  the 

le  track  of 
yn  of  sew- 
aeration  of 
ases  along 

e  develop- 


ment of  malaria  presented  by  an  elevated  and  apparently  dry 
region,  with  a  stratum  of  loose  surface  soil  nud  a  deeper 
floor  of  clay  or  some  other  impermeable  soil  beneath,  Avliero  a 
large  amount  of  surface  Avater  loaded  Avith  vegetable  ingredients 
percolates  through  the  loose  upper  earth  and  is  retained  in  the 
lower  stratum.  The  intense  heat  of  the  sun  often  causes  cracks 
and  deep  rifts  in  the  earth,  and  by  exposing  the  vegetable  mat- 
ters to  decomposition  favors  the  germination  of  the  miasm. 

5.  The  wind  exerts  considerable  intluence  in  developing  as 
well  as  in  conveying  malaria.  This  may  depend  somewhat  upon 
various  thermo-atmospheric  conditions. 

6.  All  Aveakening  influences  such  as  increased  moisture  of  the 
atmosphere,  exposure  to  excessive  solar  heat,  sudden  cooling  of 
the  cutaneous  surface,  and  inordinate  eating  or  drinking,  favor 
the  action  of  malaria.  These,  each  and  all,  act  by  disturbing 
the  equilibrium  of  the  body,  and  thus  diminishing  the  power  of 
resistance. 

Conditions  Inimical  to  tlie  Production  of  Malaria.— Pass- 
ing from  this  enumeration  of  the  favorable  conditions,  Ave  will 
now  briefly  consider  the  unfavorable  ones: 

1.  We  may  mention  the  extremes  of  latitude.  Malaria  is  sel- 
dom generated  north  of  63°  north  latitude,  or  south  of  57°  south 
latitude.  The  farther  we  recede  from  the  equator,  within  these 
limits,  the  more  feeble  becomes  the  malarial  poison. 

2.  Malaria  is  seldom  generated  beyond  1,000  feet  above  the 
level  of  the  sea. 

3.  Thorough  ditching  and  draining,  with  steady  cultivation  of 
the  soil,  prevents  any  prolonged  generation  of  malaria  in  the' 
majority  of  marshes. 

4.  An  average  temperature  below  60°  Fahr.,  is  always  unfa- 
vorable to  the  generation  of  the  malarial  poison.  This  is  a  gen- 
eral rule,  and  holds  good  everywhere. 

5.  The  daytime  is  less  favorable  for  the  development  and  ger- 
mination of  the  miasm  than  is  the  night. 

6.  Strong  Avinds  diminish  the  virulence  of  the  poison.  On  the 
other  hand  a  hot  and  diy  atmosphere  Avith  little  or  no  Avind,. 
especially  after  heavy  rains,  increases  ii 

7.  Certain  plants  are  found  to  lessen  the  quantity  of  malaria.. 
The  common  sunflower  (Helianthus  Annuus),  possesses  consid- 
erable absorbing  power,  and  has  been  used  with  great  success  in 


44 


LECTURES  ON   FEVEliS 


i  -I 
t 


the  Eastern  states.  The  Cnlamus  (ncorus  calamus  aromaticus) 
has  been  used,  and  is  recommended  by  Sebastian.  And  the 
Eucalyptus  has  been  planted  with  some  success  throughout  the 

marshes  of  Italy. 

8  At  times,  all  the  conditions  exist  that  are  necessary  to  gener- 
ate miasm,  and  yet  no  poison  can  be  found.  This  peculiar 
phenomenon  is  believed  to  be  caused  by  the  presence  of  ozone, 
which  is  largely  developed  in  some  marshes,  and  exerts,  as  you 
know,  a  paralyzing  influence  over  bacterial  life.  Examples  of 
this  may  be  found  among  the  islands  of  the  Pacific,  and  m  the 
swamp  lands  of  Australia. 

Climatic  Iiiiliiences  in  the  Genesis  of  Malaria.-The  sea- 
sons of  the  year  have  cimsiderable  influence  over  the  develop- 
ment of  malaria.     In  tropical  regions  malarial  fevers  almost 
always  arise  during  the  summer.     They  begin  al)out  the  latter 
part  of  June  or  the  first  of  August,  and  they  reach  their  acme 
Bon-Dtime  between  July  and  October.     In  colder  climates  they 
appear  in  the  spring,  decline  in  the  summer,  and  re-appear  m 
a  more  serious  form  in  the  fall.     In  temperate  climates  the  win- 
ters are  usually  free  from  malarial  diseases.     In  the  tropics  the 
more  damp  the  year  the  more  severe  the  fevers.     A  wet  spring 
and  a  hot  summer  followed  by  a  hot  autumn,  as  well  as  a  wet 
spring  and  hot  summer  followed  by  a  wet  autumn,  give  a  decided 
impetus  to  the  development  of  malaria.     During  the  summer 
there  is  a  tendency  to  implication  of  the  nervous  system  and  di- 
gestive apparatus,  while  during  the  winter  the  disposition  is  to 
catarrhal  and  inflammatory  aff-ections  of  the  respiratory  organs. 
The  quotidian  tvpe  of  intermittents  occurs  oftenest  during  the 
warm  summer  Months.     The  tertian  appears  mostly  m  autumn 
and  early  spring.     Eemittents  tend  to  follow  the  quotidians, 
and  qunrtans  are  apt  to  follow  tertians  in  the  autumn. 

Crit»i:;tl  Days.— Favorable  cases  of  fe\er  show  a  decided  tend- 
ency to  terminate  upon  what  are  called  c  -itical  days.  The  crit- 
ical days  are  the  3d,  5th,  7th,  9th,  11th,  Uth,  17th,  21st,  27th 
and  31st.  The  non-critical  are  the  intermediate  days;  but  tne 
4tli  and  Cth  are  considered  secondarily  critical.  A  seven  days' 
case  of  fever  usually  terminates  on  the  3d,  5th  or  9th  day,  and 
a  fourteen  days'  case  on  the  3d,  5th,  7th  or  9th.  Cases  that  pass 
the  7th  day  are  apt  to  go  on  to  the  11th.  The  fourth  day  of  the 
week  is  alwavs  the  indicative  day.     Hippocrates  says  that  sweats 


i-PJ.l!HLlJ|l!ll"JWW- 


CltlTK'AL   DAYS. 


45 


occurring  on  critical  days  are  salutary,  and  denote  a  favorable 
turn  in  the  disease,  while  those  which  occur  on  the  other  days 
denote  exhaustion,  obstinacy  and  relapse  of  the  disease.  My 
friend  Dr.  Ilaue,  following  Grauvogl,  thus  explains  the  doctrine 
of  critical  days: 

According  to  physiological  experiments  it  appears  that  a  liv- 
ing  organism,  when  it  is  subjected  to  a  starving  process,  does 
not  lose  its  bodily  substance  evenly,  but  rather  periodically,  so 
that  its  greatest  losses  fihvays  fall  upon  the  fifth,  eighth  and 
thirteenth  days.  Thus  the  operations  in  a  living  organism  differ 
essentially  from  mere  mechanical  or  chemical  operations.  If  you, 
for  example,  expose  a  vessel  with  water  to  an  equally  dry  atmos- 
phere, it  will  lose  its  contents  by  evaporation  evenly,  just  so 
much  an  hour.  The  living  organism  does  not.  It  regulates  its 
expenditures  or  its  losses  according  to  its  own  laws,  which  allow 
its  receipts  and  expenditures  to  oscillate  between  a  certain  bound- 
ary, and  make  its  operations  to  go  on  in  regular  periods. 

These  periodical  fluctuations  are  therefore  the  law  of  normal 
life,  part  and  portion  of  all  its  evolutions  in  health  and  disease, 
and  are  not  peculiar  to  states  of  disease.  When,  therefore,  in 
diseases  on  the  third,  fifth,  seventh,  thirteenth,  twenty-first  and 
thirty-fifth  day,  a  greater  amount  of  losses  sets  in,  in  the  form 
of  excretions,  such  as  sweat,  flow  of  urine,  diarrhea,  etc.,  which 
is  called  the  crisis,  it  is  nothing  more  or  less  than  the  same  peri- 
odic oscillation  which  is  going  on  continually  in  the  living  organ- 
ism, and  which  becomes  more  conspicuous  only  in  disease,  be- 
cause it  is  frequently  followed  by  a  decided  improvement  or 
death.  It  necessarily  must  become  more  conspicuous,  because 
this  periodical  loss  is  added  to  the  extra  consumption,  which  is 
a  condition  of  the  acute  disease.  If  the  physical  state  of  the  pa- 
tient be  such  as  to  endure  both,  he,  of  course,  must  feel  better 
the  next  day,  when  the  periodical  acme  ceases;  and  he  dies,  if 
his  physical  power  cannot  endure  the  united  action  of  both. 
Thus  the  critical  days  of  the  disease  are  nothing  more  nor 
less  than  the  normal,  periodical  fluctuations  of  the  living  organ- 
ism, with  which  they  correspond;  and  the  crisis  is  that  critical 
day  with  its  normally  increased  excretions,  which  falls  together 
with  the  height  of  the  disease. 

These  observations  are  corroborated  by  the  following  facts: 
that  the  so-called  crisis  does  not  appear,  when  during  the  course 


% 


-"?*»• 


40 


LECTURES  ON  FEVERS. 


of  a  disease  the  organiHiu  is  wcakoned  by  improper  mecUcntiou 
because  then  the  natural  periodic  tiuctuati.m  is  disturbed  and 
destroyed;  audit  does  not  appearwhen,  by  tlio  application  of  the 
proper  remedy,  health  is  restored;  Inicause  the  periodic  fluctua- 
tion alone  is  not  consi)iciyu.s  enou<,di  to  be  observed.  It  is,  how- 
ever  never  wanting  when  the  disease  runs  an  undisturbed 
couiie;  and  in  so  far  it  is  an  imi)ortant  means  to  distinguish 
between  a  successful  and  an  unsuccessful  treatment. 
Kaue  further  says,  that:  .  . 

1  The  right  remedy  cures  a  disease  with.^ut  a  crisis;  and 
thus  we  have  an  indisputable  proof  that  the  selected  remedy 

■mis  ilic  remedy.  .  .     , 

2  A<'firavation3  after  a  remedy,  when  they  occur  on  critica 
days,  need  not  be  the  result  of  the  remedy,  as  the  conjoined 
action  of  the  disease  and  the  periodical  oscillation  alone,  will 

cause  them  naturally. 

3  When  after  the  administration  of  a  homoeopathic  remedy 
n  crisis  takes  place  notwithstanding,  we  may  be  sure  we  did  not 
"hit "  the  case,  and  that  the  patient  got  well  without  our  aid. 

4  When  no  crisis  apiioars,  and  the  patient  gets  worse  and 
worse,  it  is  clear  that  we  did  not  tind  the  right  remedy,  and  we 
may  even  have  spoiled  the  case  by  wrong  means. 

Thermometry  of  Fevers.-A  few  words  on  the  temperature 
range  in  fevers  and  I  have  done.  You  all  vvell  know  that  the 
normal  temperature  in  the  axilla  is  stereotyped  at  98.GFahi.. 
and  that  it  is  about  a  degree  higher  in  tropical  than  m  temper- 
ate climates.  In  temperate  regions  it  is  highest  m  the  early 
morning  and  lowest  at  midnight,  while  in  the  tropics  it  is  lowest 
in  the  early  morning  and  highest  during  the  day.  In  children 
it  may  be  normally  one  or  two  degrees  higher  than  m  adults.  A 
temperature  rise  of  T  Fahr.  corresponds,  as  a  rule,  with  an 
increase  of  from  8  to  10  beats  per  minute,  of  the  pulse  in 
severe  diseases  the  temperatui-e  may  fluctuate  between  Jo  I'anr 

and  109'  Fahr.  The  highest  temperatures  are  found  m  scariet 
fever  and  yellow  fever.  Wunderlich,  who  has  made  a  special 
study  of  clinical  thermometry,  gives  us  the  following  charac- 
teristics: Temperatures  much  below  96.8='  Fahr.  are  collapse  tern- 
peratures;  below  92.13°  Fahr.,  deep,  fatal  algid  collapse;  JI.6 
to  9.-)=  Fahr.,  algid  collapse,  with  great  danger,  still  with  possi- 
bility  of  recovery;  9,r  to  96.8^  Fahr.,  moderate  collapse,  in  itself 


TEMl'EIi.VTUllE.S. 


47 


icntiou, 
)ed  unil 
u  of  the 
fluctua- 
is,  how- 
sturbetl 
;iuguish 


sis;  and 
remedy 

critical 
iujoiiied 
ane,  will 

remedy 
!  did  not 
ir  fiid. 
orse  and 
',  and  we 

perature 
that  the 
5^  Fahr., 
I  temper- 
he  early 
is  lowest 

children 
lults.     A 

with  an 
ulse.  In 
95°  Fahr. 
in  scarlet 
a  special 
y  charac- 
apse  tem- 
>se;  92.3° 
ith  possi- 
S  in  itself 


without  danger;  99.5^  to  100.4  Fahr.,  sub-febrile  temperature; 
1(K).4  to  101.12  Fahr.  slight  febrile  action;  101.3  to  102.2 
Fahr.  in  the  morning,  rising  to  103.1'  Fahr.  in  the  evening, 
moilerato  fever;  103.1'  Fahr.  in  the  morning  and  about  104 
Fahr.  in  the  evening,  considerublo  fever;  103.1  Fahr.  in  the 
morning  and  above  104.9'  Fahr.  in  the  evening,  high  fever; 
107.G '  Fahr.  and  above  indicates  usually  a  fatal  termination,  ex- 
cept in  relapsing  fever.  Temperatures  have  occasionally  been 
reported  as  high  as  112',  113  ,  115  and  even  117  Fahr.,  where 
patients  have  recovered. 

A  fever  temperature  of  104  '  to  105  '  Fahr.  indicates  that  the 
l)rogres8  of  a  disease  remains  unchecked. 

A  rise  in  temperature  or  a  stable  high  temperature  from 
evening  until  morning  is  generally  a  sign  that  the  patient  is  get- 
ting, or  will  get,  worse.  But  stability  of  temperature  from  morn- 
ing to  evening  is  generally  a  favorable  indication.  All  temper- 
atures should  invariably  be  taken  mf )ruing  and  evening,  and  still 
more  frequently  in  critical  cases.  The  axilla  is  generally  con- 
sidered as  the  best  place  to  take  the  temjierature,  though  in  chil- 
dren the  rectum  is"  probably  better.  And  from  three  to  five 
minutes  is  the  average  interval  between  the  insertion  and  re- 
moval of  the  clinical  thermumeter. 


■| 


fi 


MMi 


asT-- 


LECTURE  III. 

Simple  Intermittent  Fever. 

At  ray  last  lecture  I  spoke  of  the  nature  nnd  origin  of  malarial 
poison.  To-day  I  wish  to  direct  your  attention  to  the  fevers 
caused  by  this  poison.  The  first  in  the  list,  according  to  our 
classification,  is  Simple  Intermittent  Fever. 

Definition.— Simple  intermittent  fever  may  be  defined  as  a 
paroxysmal  disease,  due  to  the  action  of  malarial  poison,  and 
characterized  by  the  occurrence  of  febrile  paroxysms  (consist- 
ing usually  of  a  succession  of  definite  stages,  viz.  the  cold,  the 
hot  and  the  sweating  stage),  separated  by  intermissions  or  apy- 
rexial  periods  of  variable  length.  According  to  the  length  of 
the  interval,  the  fever  may  be  of  different  types,  viz.  quotidian, 
tertian  or  quartan. 

Synonyms.— It  is  popularly  known  as  ague,  fever  and  ague, 
chills  and  fever,  the  shakes,  swamp  fever,  etc. 

History.- The  history  of  intermittent  fever  dates  from  early 
times.  Celsus  clearly  defined  the  quotidian,  tertian  and  quartan 
forms.  Archigenes  first  recognized  the  masked  intermittents, 
and  Diomedes  Comarus  was  the  first  writer  who  described  an 
intermittent  type  of  dysentery.  Later  Rhazes  described  those 
long-lasting  types  of  intermittents,  having  no  apyrexial  period, 
where  the  chill  stage  of  a  second  paroxysm  occurs  during  the 
sweat  stage  of  the  first,  and  which  constitute  a  transition  stage 
to  the  remittent.  Intermittent  fever  is  recorded  as  having  been 
quite  fatal  in  Europe  during  the  seventeenth  century.  In  the 
early  part  of  the  present  century  it  prevailed  very  extensively 
throughout  this  country,  and  was  alarmingly  fatal.  ^ 


of  malarial 

the  fevers 

ling  to  our 

.efined  as  a 
poison,  and 
IS  (consist- 
bie  cold,  the 
ions  or  apy- 
e  length  of 
quotidian, 

:  and  ague, 

1  from  early 
and  quartan 
termittents, 
lescribed  an 
ribed  those 
3dal  period, 

during  the 
sition  stage 
having  been 
iry.     In  the 

extensively 

48 


CLINICAL   HISTUllV. 


to 


Ktlolojfjr.— Intermittont  fover  is  univorsnlly  ronrodod  to  bo 
duo  to  iimliirinl  poisoning.  Tlio  nature  of  tlic  iM)is()n  hiw  Ih'oh 
iilreudy  considered  in  n  previous  loeture.  We  will  tiierefore 
|)fiss  by  tiio  ([uestionof  ciiusation,  simply  reminding'  you  of  the 
fact,  'hat  the  preponderance  of  testimony  from  rei-eiit  investiga- 
tions tends  to  strengthen  the  theory  of  the  parasitic  tirigin  of 
the  intermittents,  and  points  to  the  bacillus  malari.u  as  the 
cause. 

(-linical   History.  -The  clinical  history  embraces  a  descrii)- 
tion  of  the  prodromal  stage,  the  three  paroxysmal  stages,  the 
intermission,  the  types,  and  the  secpielao.     The  itrodvomul  stage, 
or  the  stage  of  incubation,  is  of  variable  length,  averaging  fn>m 
six  to  eight  days.     Tliis  stage  is  not  always  present,  for  fre- 
quently, suddenly  and  without  warning,  the  paroxysmal  stage  is 
ushered  in.     The    symptoms  are  uniformly   not   very  detinito. 
The  patient  feels  tired,  and  complains  of  frontal  heailache,  pains 
in  the  loins  and  legs,  with  yawning,   stretching,  and  general 
malaise;  the  functions  of  the  stomach  are  somewhat  impaired, 
and  there  is  thirst  and  anorexia.   The  taste  is  metallic,  the  breath 
foul,  and  the  tongue  furred,  yellow  in  the  center  and  white  at 
the  edges;  the  skin  is  hot,  dry,  and  perhaps  slightly  icteric;  the 
pulse  is  small  and  frequent;  the  urine  is  scanty,  high-colorod, 
and  deposits  a  red  sediment;  the  fecal  discharges  are  dark-coloreci 
and  offensive;  these  symptoms  continue  with  more  or  less  i)rom- 
inence  from   one  to  ten  days,  and  eventually  terminate  in   a 
rigor,  which  is  the  commencement  of  that  series  of  phenomena 
which  characterize  the  paroxysmal  stage. 

Paroxysms.— A  paroxysm  of  intermittent  fever  consists  of 
three  well-marked  stages,  viz:  the  cold,  the  hot  and  the  sweating 
stage. 

Cohl  Stage  or  Chill— Thia  stage  is  usually  ushered  in  by  a 
sensation  of  chilliness  or  coldness  beginning  in  the  back,  loins 
or  extremities,  and  gradually  creeping  over  the  entire  body. 
The  skin  becomes  pale  and  shrunken,  and  presents  the  appear- 
ance of  goose-flesh  (cutis  anserina.)  The  face  becomes  pale, 
the  eyes  are  sunken,  the  nose  is  pointed,  and  the  lips  and  finger- 
ends  become  blue;  the  sensation  of  chilliness  increases,  the 
teeth  begin  to  chatter,  the  limbs  commence  to  shake,  and  the 
whole  frame  participates  in  the  general  commotion;  the  voice 


BO 


i,r.(  rriii.s  on  rEVEun. 


l„H.nin('H  w.-ak,  huskv.  nn.l  troinul.mH;  tho  respiration  hocomoft 
huni.'.l.muliHntt.n.UMl  l.y  a  m  nso  ..f  weight  nn.l  ti^'htn.'Hs  in 
tho  i-host,  and  not  untnMiu..ntly  l>y  a  hlioit,  ilry  f.m«h;  tli."  pulw' 
issmall.  (luick,  an.iniiii;  tlw  niiml  is  usually  t-lear,  but  pecul- 
iarly initablr;  .KTasionally  tlu'iv  is.l.>liiiiui«;  in  young  i-hildron, 
convulbiouH  are  apt  to  occur;  tho  tcmporatuip  ot  tho  Hurt'aco  i.f 
tho  body  iH  below  the  natural  Htandanl,  while  in  tho  nututh. 
axilla  .)r  rectum  the  thcriuoniet<>r  may  rej^ister  101  Fahr.,<)r 
10.")  Fahr;  the  mouth  is  dry.  but  the  t.mKUo  continuoH  moist; 
thirst  is  usually  urgent,  antl  nausea  is  often  a  imminent  symp- 
tom; tho  urin(>  is  im-roased  in  (piantity,  clear,  colorless,  of  low 
Hpecifii^  t^ravity,  and  does  not  dejjnsit  a  Hodiment  on  cooUu}^;  thw 
dejei'tions  are  apt  to  be  dark  and  bilious;  this  stage  lasts  from  n 
quarter  of  an  hour  to  three  hours.  Its  departure,  which  is  some- 
times abrui)t  but  generally  gradual,  is  announced  by  tho  abate- 
nu>nt  of  the  chills,  and  by  the  iii)pearanco  of  transient  flashes  of 
heat,  starting  from  the  extremities. 

IM  Slai If.— TliM  stage  is  one  of  reaction.  The  countenance 
is  no  longer  pale  and  shrunken,  but  on  tho  contrary  it  is  flushed 
and  turgid;  the  heat  of  the  surface  now  becomes  marked;  the 
temperature  rises  to  10.")^  Fahr.,  and  at  times  approaches  110 
Fahr.,  or  even  higher;  the  pulse  is  full,  strong  and  rapid;  the 
respirations  are  hurried,  but  not  oppressed;  the  headache  in- 
creases and  the  patient  becomes  extremely  restless;  the  mouth 
is  dry  and  hot,  the  tongue  parched,  and  herpetic  vesicles  occa- 
sionally  appear  on  the  lips;  thirst  is  a  prominent  and  distressing 
symptom;  the  urine  is  now  scanty,  high  colored,  and  of  high 
specific  gravity;  this  stage  may  last  from  an  hour  or  two  to 
twelve  or  sixteen  hours.     The  average  duration  is  from  three  to 

four  hours. 

SircatiiKf  Sfagr— This  stage  comes  on  gradually.  It  com- 
mences in  a  perspiration  which  appears  first  on  the  forehead 
and  face,  and  afterward  on  the  trunk  and  extremities;  the  pulse 
now  loses  its  frequency;  the  breathing  becomes  natural;  the 
urine  passes  freely,  but  retains  its  high  color,  and  deposits  a 
light  red,  lateritious  sediment;  the  headache  and  thirst  abate; 
the  fever  disappears.  The  patient  falls  off  into  a  quiet  sleep, 
and  the  state  of  apyrexia  is  established;  the  average  duration  of 
this  stage  is  from  three  to  four  hours. 

Such  is  the  normal  course  of  an  intermittent  paroxysm.     Devi- 


bocomoft 
ifncHs  ill 

[ll»>  pulHc 
at  pcc'ul- 
I'liildron, 
url'ai't'  of 
,)  iiioutli. 
Fahr.,  or 
>H  luoiHt; 
nt  syiup- 
iH,  of  low 
A'u\\i;  i\x« 
in  from  n 
1  Ih  Horae- 
lio  abate- 
tlashes  of 

mtenanco 
is  flushed 
rkecl;  the 
ches  110 
•apid;  the 
lache  ill- 
he  mouth 
icles  occa- 
listressiiig 
[1  of  high 
or  two  to 
n  three  to 

It  com- 
forehead 
the  pulse 
tural;  the 
deposits  a 
irst  abate; 
aiet  sleep, 
luration  of 


;m. 


Devi- 


I.VWrt  OF  v.vnoxYsM. 


61 


atioiiH  may  howrver  occur,  and  certain  Htages  may  at  timcH  lio 
wanting. 

I>i(tiih  (Kjiir  irt  the  popular  name  for  an  attack  from  whicli  tlie 
chill  Ih  aliHeiit,  the  fever  ami  sweat  aloim  recurring  periodic- 
ally. When  an  intermittent  pan).\yhiii  occurs  one  day,  and  an 
intense  neuralgia,  urticaria,  dyHpepsia  or  dyHentery  takes  its 
place  the  following  day,  Ave  have  what  is  termed  a  masked  iuter- 
initteut. 

Intermittent  neuralgia— very  c(minion  in  malarial  districtH  — 
may  attack  either  the  intercostal,  the  sciatic,  or  the  frontal  liranch 
of  the  ophthalmic  divisiim  of  the  fifth  nene.  When  it  attacks 
the  latter  nerve  it  is  called  "])row  ague."  In  malarial  diiutricts 
all  complaints  are  apt  to  take  on  jieriodicity. 

Internihsioil.  -During  the  intermission  the  patient  may  nt 
first  feel  ordinarily  well.  I3ut  after  repeated  paroxysms,  he  is 
npt  to  become  debilitated  and  anannic,  and  sooner  <u-  later  pre- 
sents all  the  symptoms  of  malarial  cachexia. 

Laws  of  the  Paroxysm.— The  following  laws  have  been  tab- 
ulated as  gf)verning  to  a  certain  extent  the  paroxysm: 

1.  The  shorter  the  intermission  the  hmger  the  paroxysm. 

2.  The  longer  the  paroxysm  the  earlier  it  commences  in  the 
day. 

3.  The  more  durable  the  cold  stage,  the  loss  durable  the  other 
stages. 

Types.— Intermittent  fever  is  divided  into  types  correspond- 
ing to  the  length  of  the  interval.  The  infcrml  is  the  period 
from  the  beginning  of  one  to  the  beginning  of  the  next  parox- 
ysm, and  difiers  from  the  interinission  in  that  the  latter  is  the 
space  between  the  ending  of  one  paroxysm  and  the  beginning  of 
the  succeeding  one.  Each  type,  viz:  the  qitoiidian,  the  iertian 
and  the  quarian,  observes  u  law  of  periodicity  in  the  succession 
of  paroxysms.  In  the  quoiidimi  type  the  paroxysm  recurs  every 
day.  In  the  icriian  it  recurs  every  other  day.  And  in  the 
quarian  it  recurs  on  the  first  and  fourth  days.  The  quotidian 
and  tertian  forms  are  the  most  frequent;  while  the  quartan 
variety  is  comparatively  rare.  The  tertian  type  occurs  most 
frequently  in  temperate  climates,  but  in  tropical  regions  the  quo- 
tidian prevails. 

In  this  country  these  two  types  vary  in  frequency  during  dif- 


ite — 


52 


LECTUllES  ON  FEVEllS. 


ferent  seasons.  Urfually  the  tei'tian  is  supposed  to  be  the  most 
prevalent.  But  in  the  aggregate,  according  to  Woodward,  the 
quotidian  appears  to  predominate.  For  out  of  98,237  cases  oc- 
curring in  tlie  L'nited  States  army,  51,623  were  cases  of  quotid- 
ian fever,  anil  only  •4-l:,857  cases  were  of  the  tertian  variety.  The 
quartan  type  occurs  chiefly  in  autumn,  but  even  then  is  rarely 
met  with,  except  during  jjrolonged  malarial  attacks.  The  qu  »- 
tidian  and  tertian  types  prove  more  obstinate  in  autumn  than 
at  any  other  season  of  the  year.  The  latter  variety  occurs  nKjre 
frequently  in  adxilts  than  in  children,  and  attacks  the  sanguine- 
ous temperament  oftener  than  the  leucophlegmatic.  In  the  quo- 
tidian tyi)e  the  paroxysm  usually  recurs  in  the  morning  (daily), 
and  lasts  from  8  to  10  hours.  In  the  tertian  it  recurs  about  noon 
(of  the  third  day),  and  lasts  from  G  to  8  hours.  While  in  the 
qiiart  n  it  recurs  in  the  afternoon  or  evening  (of  the  fourth 
day),  and  lasts  from  4  to  G  hours. 

Other  types  are  mentioned  by  various  writers,  such  as  the 
quinian,  in  which  the  paroxysm  recurs  on  the  fifth  day;  the  sex- 
tan on  the  sixth;  the  scpian  on  the  seventh:  the  ocian  on  the 
eighth,  and  so  on.  Such  cases  are  however  great  rarities,  and 
are  looked  upon  as  simply  curiosities  of  clinical  experience.  In 
addition  to  these  simple  types  we  have  mentioned,  irregular 
compound  forms  are  occasionally  encountered.  Thus  a  double 
quotidian  may  be  presented  with  two  paroxysms  daily:  one  severe 
in  the  morning,  and  the  other  mild  in  the  afternoon  or  evening. 
Or  a  double  Icviian  with  a  paroxysm  daily;  the  paroxysms  dif- 
fering on  successive  days,  but  corresponding  in  every  respect  on 
alternate  days.  Or  finally  a  double  qnavfan  may-  appear  in 
which  a  paroxysm  recurs  on  two  successive  days,  but  is  absent 
on  the  third  day.  The  double  ieiiian  is  the  most  frequent  of  the 
compound  types. 

As  regards  the  regularity  of  its  appearance,  a  paroxysm  may 
be  either  anticipating  or  postponing.  When  it  recurs  a  little 
earlier  each  day  it  is  called  an  anticipating  paroxysm.  And  it 
is  called  a  postponing  paroxysm  when  it  recurs  a  little  later  each 
time.  An  anticipating  paroxysm  shows  that  the  disease  is  pro- 
gressing, and  is  not  being  controlled  by  remedies,  while  a 
postponing  paroxysm  indicates  that  the  disease  is  not  only  be- 
ing controlled,  but  is  about  to  end.  When  a  relapse  occurs  it  is 
usually  at  the  end  of  seven,  fourteen,  twenty-one  or  twenty- 


■^SiS^^ammi 


the  most 
hvnrd,  the 
1  cases  oc- 
o£  quotid- 
i-iety.  The 
ti  is  rarely 

The  qu  .- 
umn  than 
curs  more 

sanguine- 
En  the  quo- 
ig  (daily), 
about  noon 
lile  in  the 
the  fourth 

iich  as  the 
y;  the  sex- 
tan on  the 
irities,  and 
rience.  In 
I,  irregular 
IS  a  donhle 
:  one  seA'ere 
or  evening. 
3xysms  dif- 
r  respect  on 
.  appear  in 
it  is  absent 
luent  of  the 

oxj'^sm  may 
curs  a  little 
im.  And  it 
le  later  each 
ease  is  pro- 
les,  while  a 
lot  only  be- 
I  occurs  it  is 
or  twenty- 


ANALYSIS    OK    CHAKT. 


5:^ 


eight  day.  from  the  last  paroxysm.  Patients  cannot  be  con- 
.  idered  beyond  he  danger  of  a  relapse  until  six  or  eight  Meek~ 
have  elapsed  without  an  attack. 

CHART  n.~Sh)ip]r  Infrniiit/riif  Fern: 


Types; 


I'crlods: 


QiK'ti.liiiii;  Toiiimi:  (.>uiiitiiri:   n.ml.l,.  T,iii,m. 


liicHliatkin, 


rmi>\,vsiiiiil   I'l'iiod. 


<'il|il  stiig-c, 


Diirntioii:      n  to  s  duvs. 


'i  lir.  to  S  hrs, 


Hot  stiijfe, 


I!  1i)  4  Ikjui'!". 


Initiiil 
>,'.  iiiptoms 


Tcrniicfii- 
tiMv: 


I'll  ISO ; 


('•  I'll  orul 
miilitise. 


Mii.v  (II-  iimv 

not  he  slijrht'lv 

iiliovc  the 

noniitil. 


Siiiull  tiiiil 
li'fi|ii<.'iit. 

w  to  ion 
pi'v  iiiiiiuto. 


rroci)intr      I     Hotliiishfs 
fliills.  stiiriiiiK'  tinin 

inliiK'k.       !  cxticiiiilios. 


."tUM-p. 


riiocrriilii. 

int'riijfc. 

'i  to  -t  hours. 


Intermission. 


•i  hours 

to 
:i  il.ivs. 


Pcrspiriition 
on  lorehi'iKl. 


lot)"  F.  to 
lO.-."  F. 


Ui'spi  ra- 
tion: 


Normal, 


Sliin: 


Trine: 


Tong-uo: 


Dry. 


Scanty  and 
highooli.red, 


Intestinal 
Canal: 


Xervous 
system : 


Furred,  yellow 

in  center 

and  white  at 

edjsres. 

metiiilie  taste, 


."^niail,  (|ui(k 

and  haril, 

IHI  to  l:.'() 

per    minute. 


lil.V  F.  to 
I  Id'  F, 


Kiipidly 
iipproaehes 
the  normal. 


Full,  stroinj- 

and  rapid, 

llUto  14(1  per 

minute. 


Hurried  and      Hurrie.l  lait 
"I'Pi'essed,     imt  ojjpressed 


Cold.  Face 
pale  and 
shriinkeii. 


Hot.    Face 
flusheil. 


NV-aWy  normal 

iMit  weak. 

'Oto  s.')  |)ei 

minute. 


Xoiinal, 


Moist. 


Profuse  and 

colorless. 

low  sp.  trr. 


Anorexia. 
Dark  lecal 
discharjiies. 


Frontal 
headache. 


Scanty, 

hijfh  colored. 

hi»fh  sp.  »!r.. 

dep.  of  urates, 


Moist 

and  furred. 

Thirst, 


Parched 
with 
thirst. 


Copious 

lait 

hijfh  i()l<ired. 


Moist. 


Xnusea  and  vomitinu- 
Uilious  dejections. 


Headache, 
mind  clear, 
luit  irrital)le, 


Duration: 


Sei)uels: 


Increased 
iK'iidache, 

••xtreiiie 
rr'srlessness. 


i« 

u 

e 


Duration  of  the  <lisease  is  indetlnite. 


Etiolofry: 


Ana-mia,     Enlargement  of  Spleen  (-avuc-eake-j      x,.„ 
__^    "J^-e  iuK(    I,    Anasarca  una  dropsy, 

lliicillus  Malaria\ 


Malarial  poisoninji-. 


ANALYSIS   OF   CHAKT. 

The  Nervous  S.vsteni.-A  chill  more  or  less  severe  „s,„llv 
marks  the  onset  of  the  attack;  headache  is  ver,- common  °"d 


I 


54 


LECTUKES   ON   FEVERS. 


i! 


occurs  ns  an  early  symptom,  it  is  usually  frontal,  but  occasion- 
ally it  becomes  general;  delirium  is  rare,  and  when  it  exists  is 
but  transitory;  restlessness  is  frequently  quite  marked  during 
the  paroxysmal  stage.  Hypera^sthesia  of  the  cutaneous  surface 
in  the  region  of  the  first  dorsal  vertebra,  is  frequently  associated 
with  pain  in  the  back  of  the  neck. 

The  Temperature.— The  temperature  rises  with  great  rapid- 
ity. During  the  initial  chill  it  is  often  as  high  as  104°  Fahr., 
and  may  reach  105  °  Fahr.  or  even  110°  Fahr.  in  the  hot  stage. 
The  defervescence  is  frequently  as  sudden  and  marked  as  the 
temperature  rise.  During  the  intermission  the  temperature  is 
normal.  • 

The  Circulation.— The  pulse  is  variable.  It  is  increased  in 
frequency  especially  during  the  paroxysmal  stage.  At  the  period 
of  highest  temperature  it  is  apt  to  be  full  and  bounding. 

The  Digestive  System.— Nausea  and  vomiting  sometimes 
accompany  the  initial  chill.  There  is  usually  loss  of  appetite, 
thirst,  impaired  taste  and  a  coated  tongue;  the  evacuations  are 
commonly  offensive  and  of  a  dark  color. 

The  Secretious.— The  urine  is  diminished  in  quantity  during 
the  incubative  period  and  in  ;he  hot  stage.    Its  color  is  darker 
than  natural,  except  during  the  cold  stage.     The  specific  gravity 
is  above  normal  in  the  hot  stage,  but  below  it  in  the  stage  of 
chill.     The  amount  of  urea  excreted  increases  rapidly,  reach- 
ing its  maximum  at  the  beginning  of  the  hot  stage.    The  cuta- 
neous surface  is  moist  and  cold  during  the  chilly  stage,  but  dry 
and  hot  during  the  hot  stage.     The   perspiration  during  the 
sweat  stage  may  be  either  copious  or  slight,  and  has  a  "fresh- 
baked  brown  bread"  odor.     A  sallow  or  icteric  hue  generally 
attains  in  long  lasting  cases.   Herpes  labialis  frequently  appears. 
Sequels.— Anremia  is  very  apt  to  occur  in  cases  of  long  dura- 
tion.    And  in  protracted  intermittents,  as  in  those  which  have 
been  marked  by  repeated  relapses,  a  chronic  malarial  cachexia 
frequently  obtains,  characterized  by  sallow  skin,  anasarca  and 
generally  dropsy.     While  in  still  more  severe  cases,  amyloid  de- 
generation of  the  kidneys,  liver  or  spleen  may  supervene. 

Morbid  Anatomy.— Anatomically,  simple  intermittent  fever 
presents  no  characteristic  lesions  other  than  those  of  hyperaimia. 


»»<t-...i:Wi? 


ccasion- 
exists  is 
.  during 
surface 
sociated 

vt  rapid- 
=  Fahr., 
tot  stage, 
d  as  the 
rature  is 

• 

reaced  in 
le  i)eriod 

3metime» 
appetite, 
tions  are 

ty  during 
is  darker 
ic  gravity 
stage  of 
ly,  reach- 
riie  cuta- 
;e,  but  dry 
oring  the 
a  "fresh- 
generally 
y  appears. 

long  dura- 
hicL  have 
1  cachexia 
sarca  and 
nyloid  de- 
ene. 

tent  fever 
yperaeniia. 


UlFFEllENTI.VL   DIAGNOSIS. 


55 


The  blood,  which  is  the  vehicle  of  the  poison,  undergoes  certain 
changes.  A  diminution  in  tin;  number  of  red  cori)Uscles  and  a 
decrease  in  the  amount  of  fibrin  invariably  take  place.     The 

Fiu.  J>. 


O// 


/      \ 


If' 


•"V 


.V     '^_o 


Microspopical  appearance  of  the  blood  in  Jliilavial  iVverw.     a.  h.  V>iH-\\hny 
lilunient.s,     r.  Spore-productH   svi-n    during  told  stas;*' of  iiittiiiiitli.'nl 
fever,     il.  I'iiiiuent    uranuli'S. — N.  1?. — Tlic    red  blood-discs 
'  furnish  a  scale  for  measurement. 

presence  of  black  rir^mont  granules  (Fig.  9)  has  been  fully 
demonstrated  by  Kel'x  ■Richard  and  others.  And  the  bacillus 
malariio  has  been  •  .  j'  in  the  blood,  liver  and  spleen,  by 
Cuboni  and  Marchiai  ;.  These  changes  in  the  composition 
of  the  blood  are,  however,  not  so  well  marked  in  intermittent, 
as  in  remittent  and  pernicious  mnliirial  fever.  The  spleen 
and  liver  are  apt  to  become  more  or  less  enlarged  from  hyper- 
jemia.  The  former  organ  especially,  may  become  enormously 
enlarged,  and  distending  the  abdominal  wtdls  constitute  what  is 
vulgarly  styled  "ague-cake." 

Ditfereiitial  Diagnosis.— The  differential  diagnosis,  of  simple 
intermittent  fever  is  by  no  means  difficult.  A  well  marked  case 
can  hardly  be  mistaken  for  anything  else.  Latent  and  masked 
intermittents  are  perhaps  more  difficult  of  recognition.  The 
only  diseases  Avith  which  it  may  be  confounded  are  remittent 
fever,  pyremia  and  the  hectic  of  tuberculosis.  From  remittent 
fever  it  may  be  readily  distinguished  by  the  fact  that  in  remit- 
tent fever  there  is  no  intermission.  This  stage  is  always  present 
in  intermittent  fever.  The  temperature  during  the  remission 
in  remittent  fever  is  one  or  two  degrees  higher  than  normal ; 
while  in  intermittent  fever  the  temperature  falls  to  the  natun.l 


It 

i 


M 


MMIIIilll 


CC) 


LECTU11E8   ON   rKVEllS. 


Btaiulard  during  tho  intermission.     Remittent  fever  usually  1ms 
but  one  cliill,  whilf  in  intormittent  fever  a  chill  inaugurntee 
each  puroxvsm.     From   pyii-mia  it  may  be  distinguished  almost 
as  readily  as  from  the  remittents.     The  accession  of  the  fever  in 
i)y,'T'miii  observes  no  regularity,  and  there  is  no  complete  inter- 
mission.    WluMvas,  in  intermittent  fever  the  febrile  paroxysm 
comes  on  at  regular  intervals,  and  there  is  always  a  complete 
ii,t(>rmission.     In  pviPmia  the  chill  is  short,  the  fever  runs  high, 
and  the  sw(>ating  stage  is  gsnerally  prolonged.     The  temperature 
in  ])yiBmia  never  approaches  the  normal,  while  in  intermittent 
fever  there   is   a  period  of  complete  defervescence.      Febrile 
paroxysms  resembling  those  of  intermittent  fever  are  occasion- 
ally noticed  in  connection  with  tubercular  phthisis.    In  the  hec- 
tic of  tuberculosis  the  paroxysms  occur  oftener  in  the  afternoon 
than  in  the  forenoon,  and  the  intermissions  are  incomplete. 
AVhereas,  the  reverse  obtains  in  true  intermittent  fever.     The 
principal  element  in  the  diagnosis,  however,  is  obtained  by 
physical  exploration.     For  in  tuberculous  disease  the  character- 
istic physical  signs  are  seldom  wanting.     Finally,  it  should  be 
remembered  that  paroxysms  resembling  those  of  intermittent 
fever  are  frequently  produced  by  catheterism  and  other  opera- 
tions on  the  urinary  passages. 

Prognosis.— The  prognosis  in  simple  intermittent  fever  is  as 
a  rule.lfavorable.  The  tertians  are  the  most  easy  of  cure,  while 
the  qilartans  are  the  most  obstinate;  the  quotidians  are  the  most 
serious  in  their  results.  The  prognosis  in  masked  intermittents 
is  generally  favorable.  An  anticipating  paroxysm  is  an  unfavor- 
able sign,  while  a  postponing  paroxysm  is  usually  favorable.  The 
presence  of  ansemia  or  dropsy  vitiates  the  prognosis,  as  it  in- 
dicates the  development  of  malarial  cachexia.  Relapses  are 
common. 


&i^ 


nlly  1ms 
igurntee 
1  almost 
I  f  evor  ill 
te  inter- 
aroxysm 
jomplete 
ins  high, 
perature 
srmitteiit 

Febrile 
sccasion- 

tho  liec- 
ifteruoon 
3omi)letp. 
-er.  The 
ained  by 
haracter- 
houkl  bo 
ermittent 
er  opera- 

Eever  is  as 
ure,  Avhile 
3  the  most 
jrraittents 
1  uiif  avor- 
rable.  The 
,  as  it  in- 
lapses  are 


LECTURE  IV. 


Simple  Intermittent  Fever.-(Cox 


XTIXUED. ) 


TKEATMEXT. 


I  Will  mnte  your  attention  to-day  to  tlie  treatment  of  Simple 
Int  mittent  Fever  Many  are  the  books  that  have  been  w  kfen 
on  this  subject  and  innumerable  the  writers  Mho  have  tried  to 
definitely  outline  its  course.     And  yet  our  therapeut  cs  ca 

standing  all  that  has  been  written,  wo  have  nothincr  better  t.. 
offer  you  this  morning  than  the  advice  given  bv  Halm  man 
^ngyearsago   VIZ.:   Let  the  totality  of  the  symptoms  lerou 
chief  guide  in    he  selection  of  your  remedy.     To  individualize 
each  case  ch,sely  is  your  only  choice.    As  you  watch  the     q^^^^^^^^^^^ 
of   ymptoms  m  your  search  for  a  remedy,  two  similars  will  get 
eially  appear  before  you.     The  one  general  in  character   and 
corresponding  with  the  symptoms  which  are  diagnostic  of  tfe 
disease;  and  the  other  special,  and  correspondingVit  i^ec^iHa 
symptoms  which  characterize  each  individual  case.     The  latte 
IS  of  more  importance  than  the  former  in  making  the  selection 
Other  things  being  equal  the  symptoms  of  tl/paroxylnf  a 

If    l^      t  importance  as  those  of  the  intermission     Look 
then  to  the  intermission  for  the  leading  indications.     Watch  the 

TkeTh^t  r    ""T-  >f  fi-«"y  rely,  whenever  you  can 
make  the  selectxon,  on  the  single  remedy  which  covers  the  symp- 

in"the  case         ^'"'''''^''"'  ''"'^  *^''  iutermiBsiui..  and  is  the  special 

The  best  time  to  administer  the  remedy  is  during  the  inter- 
mission.     Li  severe  cases  it  may  be  coutinue.l  into  an.l  through 

57 


Tk 


58 


LECTVnES  ON   FEVEIW. 


the  paroxysm.     Beware  of  too  frequent  clmngeB  of    he  remedy 
Fm.    s  luu,  -  the  i,nro.ys,n.  continue  to  dechne  n.  duration  and 
intensity,  the  patient  is  doinj^  well  and  there  is  no  necessity  for 

a  change.  x     k„ 

Touchi),g  the  question  of  p..tency,  let  mo  adviHO   you  t.,  be 
neither  high  n..r  low.  exclusively.     For  the  high  attenuatu.n.st, 
u       e  one  hand,  is  apt  to  lose  sight  of  his  patient,  and    he 
c  u   dion   of  the  disease,  in  his  desire  for  altitude;  while  the 
w  a  tenuationist.  on  the  other,  who  lives  only  in  the  lower 
tetum  of  the  law  of  shnilars.  fails  to  reap  all  the  benehts  capable 
oi  bein.'  derived  from  a   more  generous  comprehension  of   its 
truths  °The  practice  which  has  been  the  most  successful  m  the 
-eatmentof  intermittents  is  to  use  the  U>wer  attenuations  in 
recent  cases,  and  the  higher  attenuations  m  the  chronic  forms. 

Laws  of  Selection,  etc.-As  tending  to  further  guide  you  in 
the  selection  and  administration  of  the  remedy,  we  will  formu- 
late the  following  laws: 

i.  Individualize  each  case. 

2.  Follow  the  t(^tality  of  symptoms. 

n  Grade  the  symptoms.  Give  special  prominence  o  those 
peculiar  to  the  patient;  select  as  next  in  i^^l-^'^^^f  *  V^^^^^^; 
pearing  during  the  intermission;  and  supplement  both  ^Mth 
the  symptoms  of  the  paroxysm. 

4  Never  change  a  remedy  when  the  paroxysms  are  lessening 

in  duration  and  intensity.  .      . 

^In  acute  cases  use  the  low  attenuations;  in  chronic  cases 

use  higher  attenuations. 

Pronliylaxis.-Kesidents  in  malarial  districts  shoiild.  as  far 
as  possible,  avoid  over-fatigue,  exposure  to  f  ^^-^^^^^^^^^^ 
temperature,   dietetic  errors,   and  excesses  of  f  Vi^^ile 
sleeping  apartments  should  be  in  the  upper  part  of  the  house 
so  as  o  be  above  the  stratum  of  malaria  which  is  denser  the 
neai^   the  approach  to  the  earth's  .urfaco.     Susceptible  individ- 
ua       1  ould    emain  in-doors  at  night.    When  late  evening  and 
L%  mling  exposures  cannot  be  avoided,  a  respimtor  should 
be  worn     At'all  Les  respiration  should  take  place  through  the 
nos^ils.  and  the  mouth  kept  closed.     The  food  should  be  nour- 
•         shtr'and  taken  with  regularity.     All  contaminated  water. 


remedy. 
itu)ii  and 
3ssily  fci" 

oil  io  he 
uivtioi'ist, 
nnd  tho 
kvhile  the 
kho  lower 
;s  capable 
on  of  its 
iful  in  the 
lations  in 
c  forms. 

de  yon  in 
ill  formu- 


e  to  those 
I  those  np- 
both  with 

3  lessening 

ironic  cases 

oiild,  as  far 
changes  of 
iinds.     The 
f  the  house, 
denser  the 
Lble  individ- 
Bvening  and 
rator  should 
through  the 
uld  be  nour- 
lated  waters 


I'laXCII'AL  REMEDIES. 


o9 


should  be  boiled  and  filtered  before  used.  And  breakfast  should 
always  be  taken  before  going  out  in  the  morning  air.  Flannel 
or  silk  should  bo  worn  next  the  skin.  When  nuilarial  fevers  are 
prevailing  qmrnne  3x,  gclscminm  3j,',  or  alstonia  conslrida  Ij; 
may  be  given  morning  and  evening  as  n  preventive. 

Principal  Reniedies.-Cjuinine.-Our  sheet  anchor  in  the 

treatment  of  simple  intermittent  fever  is  quiiunc,  for  no  other 
remedy  is  so  frequently  the  similimum  for  a  case  of  ague.  And 
so  generally  is  it  indicated,  that  there  is  room  for  doubt  whether 
in  intensely  malarial  districts  intermittent  fever  can  be  arrested 
without  its  use.  An  additional  reason  for  its  frequent  use  exists 
in  the  fact  that  it  has  the  power  to  destroy  the  bacillus  malaritc 
in  the  blood. 

Truly  it  is  a  most  potent  aid  in  malarial  diseases.  And  as  the 
Master  laid  the  foundations  of  homosopathy  in  cinchona  bark, 
we  can  ill  afford  to  esteem  it  slightly.  Our  In-ethren  of  the  old 
school  have  woefully  abused  it  with  their  massive  doses.  For  when 
quinine  is  adapted  to  a  case  it  will  cure  it  in  small  doses,  and 
will  cure  it  quickly.  Large  doses  of  the  drug  are  apt  to  produce 
toxical  effects  and  generally  the  patient  is  made  worse  instead  of 
better.  The  severest  type  of  malarial  cachexia  is  often  induced 
by  over-dosing  with  quinine.  Quinine  is  especially  adapted  to 
acute  intermittents  of  the  tertian  type.  The  more  perfect  the 
intermission,  the  stronger  is  the  indication.  In  chronic  inter- 
mittents and  in  malarial  cachexia  it  will  seldom  prove  a  remedy. 

The  proper  time  to  administer  quinine  is  during  the  intermis- 
sion. You  may  give  it  in  varied  strength,  from  the  second  trit- 
uration  to  two-grain  doses  of  the  drug.  And  in  occasionally 
severe  forms  of  simple  intermittent  fever,  such  as  may  occur  in 
intensely  malarial  regions,  the  hypodermatic  injection  of  the  bi- 
sulphate  of  quinine  as  recommended  in  pernicious  malarial  fe- 
ver, may  render  excellent  service.  It  will  sometimes  happen  to 
you  in  practice,  that  the  picture  of  a  case  cannot  be  made  to 
correspond  closely  with  the  picture  of  the  nearest  remedy,  and 
that  consequently  the  correct  similimum  cannot  be  reached.  lu 
such  cases  quinine  may  be  given  from  one  to  three  hours  before 
the  paroxysm,  and  the  most  nearly  similar  remedy  during  the 
fore  part  of  the  intermission.  For  time-honored  experience  has 
demonstrated,  that  when  so  administered,  it  curtails  the  parox- 


_.^-_.^^...^__.S 


<50 


LECmtES  ox   FEVKllS. 


ysnis,  hiiHtons  tlio  cure,  mid  <loes  not  in  any  way  interfere  A\ith 
tlie  uctit)n  of  the  chosen  remedy. 

Ai-sciiieiliii  alb.  ranks  next  to  quinine.     It  differs  markedly 
fium  tlio  latter  in  this,  thattlio  more*  widely  the  paroxysms  vary 
from  the  typical  form,  the  better  it  is  indicated.     Some  of  the 
Kta^'es  of  the  paroxysm  may  be  M-anting.     The  fever  stage  may 
recur  alone.     There  may  bo  no  preceding  chill,  nor  following 
sweat,  and  tlie  intermission  may  be  oftentimes  but  poorly  marked. 
Unusual   functional  derangement  of  the  alnUiminal  organs  fre- 
quently appears  in  the  arsenic  cases.     The  prostration  is  gener- 
ally greatest  after  the  hot  stage.     Arsenic  is  apt  to  be  needed  iu 
inqxii-ted,  slow  developing  intermittents,  and  especially  when 
there  is  a  dropsical  tendency.     It  is  an  important  remedy  in 
"brow-ague,"  and  iu   the  afternoon   intermittents  of   niu'sing 
chiUlren.     And  it  is  often  required  where  quinine  has  been  used 
to  excess.   It  vies  with  uatrum  muriaticuni  and  ferrum,  in  chronic 
malarial  cachexia. 

The  Arseniate  of  Quiiiia  has  been  used  with  success  in 
masked  intermittents,  and  in  mixed  types  of  simple  irtermittent. 

Ipecac  is  frequently  called  for  iu  mild  intermittents  of  the 
tertian  type.  It  resembles  arsenic  in  many  particulars.  But 
its  i)rostration  is  always  greatest  during  the  chill,  while  that  of 
arsenic  reaches  its  maximum  after  the  heat.  The  gastric  symp- 
toms are  apt  to  predominate  during  both  the  paroxysm  and  in- 
termission. The  intermission  is  seldom  very  complete.  Ipecac 
will  prove  useful  in  cases  that  have  been  drugged  with  quinine 
or  arsenic.  It  should  ahvays  be  thought  of  and  compared 
with  Pulsatilla  when  relapses  are  brought  on  by  errors  in  diet. 
And  in  obscure  cases  it  will  frequently  be  a  valuable  remedy. 

Oelseiiiilliil  follows  ipecac  Avell,  and  is  oftenest  indicated  in  the 
quotidian  type  of  simple  intermittent.  It  vies  Avitli  arsenic  in 
inq)orted  and  slowly  developing  cases,  and  with  eupatorium  in 
such  as  have  a  tendency  to  run  into  remittents.  The  intermis- 
sion is  apt  to  be  short,  and  the  paroxysms  recur  with  marked 
regularity.  Gelsemium  is  a  ^  aluable  remedy  in  children's  inter- 
mittents, and  when  relapses  occur  from  sudden  emotions. 

Natrnni  mnriaticillll  is  our  best  remedy  in  chronic  and  badly 
treated  cases.     It  is  also  adapted  to  recent  cases,  and  especially 


LEADIXC)   INDICATIONS, 


61 


such  an  ,j,,poar  in  nouly.s.ttled  .listriotH.  Tho  paroxy.rns  recur 
»  <uiy.  ^atrmn  umv.  ,s  a  c.uamn  aucl  elKcieut  remedy  fur 
chronic  malarial  cachexia.  ^ 

Niix  vomica  ia  on«  of  the  more  important  remedies  for  both 

he  quotidian  and  tertian  types.     Its  par.,xys„Ks  are  usually  irrej 

ular  and  show  a  decided  tendency  to  anticipate.     The  gastrt 

and  bdious  sy„.ptoms  are  generally  prominent,  and  bronchial 

complications  may  co-exist.  ^^"tuiui 

wh^n'tj!"'''  '"  ""'^"\",'  '"'"'  "^'  ""  «l'«"g^«ble  character,   and 
when  the  paroxysms  take  on  a  mild  form  and  appear  mostly  in 

n  pregnant  women,  when  there  is  a  tendency  to  aborticm.     Re- 
lapses  from  improper  diet  are  frequently  cured  by  this  remedy. 

unfrTh*  -'r'^"^  •"  '""'^  ""''"  "^^""^"S  ^»  "«r™"«  individ- 
uals.   The  intermission  is  usually  complete.     Ignatia  frequently 

changes  the  type  and  almost  always  postpones.     It  is  the  rem^ 
edy  for  tertians  that  change  to  quartans. 

EHpatorinin  perf.  is  indicated  in  those  severe  types  of  inttr- 
mittent  that  approach  the  remittent,  and  are  marked  by  a  very 
imperfect  intermission.  "Aching  of  the  bones"  is  its  great 
charactens  10.  «' Boneset  tea  "  is  a  well-known  popular  cufeTn 
malarious  districts,  for  "fever  and  ague."  For  the  double  ter. 
tian  type  of  intermittent  it  is  a  most  valuable  remedy. 

Capsicum  will  occasionally  be  of  service  in  simple  intermit- 
tents  occurring  during  the  summer  months. 

Cedroii  and  Aranea  are  adapted  to  intermittents  of  new  dis 
tricts  m  warmer  climates,  when  the  paroxysms  recur  with  clock 
Ike  regularity^  And  Pohjporr^s  officinalis. nAp.  pinicJ^^L 
recommended  by  our  western  physicians  as  remedies  for  the 
quotidian  type  of  simple  intermittent  fever. 

Leading  Indications-The  leading  indications  for  these,  our 
mam  remedies  for  simple  intermittent  fever,  as  well  as  for  oth- 
ers that  are  occasionally  of  service,  may  for  convenience  of 
study  be  arranged  according  to  the  following  compilation: 

Aconite.-In  recent  cases  occurring  in  dark-complexioned, 
plethoric  young  porsons.  and  in  relapses  from  exposure  to 
changes  of  temperature;  great  thirst  for  small  quantitie'sof  coH 


Si 


m 


LECTU11E8  ON   IEVEK8. 


wftter  prevails  daring  the  pnroxyHiu  Uns.  niul  nat.  vmr.,  opp. 
bry. ) ;  the  pulso  is  throady  .luring  tlie  chill,  but  £ull,  Imrd  nnd  iiv. 
queut  during  the  fever;  the  chill  piiHses  from  the  feet  to  the 
chest  nnd  head,  and  coldness  is  caused  by  the  slightest  move- 
Hient  {nux).  The  fever  runs  high  nnd  is  npt  to  be  prolonged; 
it  is  frequently  nttended  with  cough;  there  is  great  restlessnesf,, 
anxiety  nnd  nervous  excitnbility;  the  sweat  is  frequently  profuse 
and  brings  relief  {nat  WHr.,  opp.  mere). 

Ammonium  miir— Is  adapted  to  fat,  lazy  people.  Chilliness 
recurs  as  often  as  the  patient  awakes.  During  the  heat  there 
is  redness  of  the  fnce,  and  stinging  sensation  in  the  skin  (ajns, 
nif.  acid)i  flushes  of  heat  with  profuse  sweat  on  the  extrem- 
ities. ' 

Anacardiiim.— In  nervous,  hysterical  females,  and  in  nursing 
children;  mild  intermittents  in  hypochondriacs;  patient  is 
very  irritable  and  pa8sii)nate  (  bry.,  cham. ) ;  shivering,  as  from  cold 
water  down  the  back;  the  fever  returns  every  afternoon  at 
four  o'clock  ( lycop. ) ;  sweat  principally  on  the  chest  and  abdomen ; 
dull  pressure  as  from  a  plug  in  different  parts  is  very  character- 
istic. 

Alstonia.— After  abuse  of  quinine;  great  debility  and  extreme 
prostration;  rigors,  cold  sweats  and  diarrhea;  useful  in  masked 
intermittents  with  dysentery. 

Antimonium  criid.— Especially  suitable  for  aged  persons  and 
young  people  who  grow  fat;  predominance  of  gastric  symptoms 
{ipec,  puls.,nux);  thick,  milky  white  coating  on  the  tongue 
{bry.,  mere,  mix) ;  great  sadness,  and  a  woeful  mood;  aversion  to 
food;  strong  desire  for  acids,  particularly  pickles  {ar8.);  alter- 
nate constipation  and  diarrhea;  absence  of  thirst  (imh.,  quimne) ; 
great  desire  to  sleep  (opjs);  the  chill  appears  about  mid-day; 
chilliness  predominates  (menycmihea);  vomiting  during  the 
heat  {nai.  mur.);  pulseirregular  and  rapid;  sweat  comes  imme- 
diately after  the  chill  with  the  heat,  but  soon  disappears,  dry 
heat  continuing. 

Apis  mel.— Is  often  useful  in  quotidian  fevers,  and  in  pro- 
tracted and  badly  treated  cases;  the  sweat  stage  may  be  absent; 
there  is  great  desire  to  sleep;  awkwardness;  soreness  of  limbs 
and  joints;  great  sensitiveness  to  touch  and  pressure;  soreness 
in  the  region  of  the  spleen;  general  oedema;  urine  scanty  and 


mur.,  opji. 
ml  niul  fip- 
feet  to  the 
test  move- 
prolonged; 
sstlesBiiesfe, 
tly  pi'ofuse 

Chilliness 

heat  there 

Bkin  {ajns, 

he  extrem- 

l  in  nursing 
patient  is 
as  from  cold 
fternoon  at 
id  abdomen; 
y  character- 

aud  extreme 
il  in  masked 

persons  and 
ic  symptoms 

the  tongue 
[;  aversion  to 
ar8.);  alter- 
h.,  quinine); 
>ut  mid-day; 

during  the 
3omes  imme- 
appears,  dry 

and  in  pro- 
ay  be  absent; 
less  of  limbs 
lire;  soreness 
e  scanty  and 


LE.VDINCl   INDICATIONS.  ^ 

liigh-colored;  white  tongue,  witli  diarrhea  {nuL  crml);  chilli- 
ness from  motion  or  uncovering  ^niix);  chill  about  3  r  m  • 
worse  in  a  warm  rc»,.m  „r  near  a  stove;  it  begins  in  front 
of  chest,  abdomen  and  knees;  urticaria  as  the  chill  passes  off- 
urticaria,  with  intolerable  itching,  at  night  {am.,lv,l.);  thirsi 
witli  the  chill  ( ,,,n.,  caps. ) ;  no  thirst  with  the  heat  (puis. ) ;  desire 
for  milk;  during  the  i)aroxysm  oppre8si(m  of  the  chest  with  a 
sensatum  of  smothering.  Xatrum  mur,  ioUow>i  apis  well,  but 
rhua  iox.  does  not. 

Aranea.-Long-lasting  chill  witliout  thirst;    heat  and  sweat 
often  absent;  paroxysms  at  the  same  hour  every  day  or  every 
other  day  (rcdron)',  chilly  feeling,  worse  on  rainy,  cold  days 
{rhns);  headache,  better  in  the  openair;   nocturnal  toothache; 
tongue  slightly  coated,  with  bitter  taste;  nausea  and  anorexia; 
weight  in  epigastrium  as  from  a  stone  ( hry.,  ars.,  puU ) ;  enlarged 
spleen;  menses  too  early  and  too  profuse;  heaviness  in  the  limbs 
so  that  she  can  scarcely  move  them;  numbness  in  the  ring  and 
small  finger,  and  along  the  perii>hery  of  the  ulnar  nerve  (coninm). 
Arnica.— In  sanguine  temperaments  and  after  abuse  of  qui- 
nine; relapsing  cases;  especially  when  there  is  a  bruised,  sore 
feeling;  must  lie  down,  yet  the  bed  feels  too  hard  (bapf.)-  in- 
difterent  mood;  forgets  the  word  he  is  about  to  speak  {baryta 
r/uis.);  eructations  bitter,  and  like  rotten  eggs  (cham.);  offensive 
flatus  smelling  like  rotten  eggs;  drawing  pains  before  the  chill- 
chill  in  afternoon  or  evening,  most  severe  in  the  pit  of  the  stom-' 
ach,  with  thirst  for  large  quantities  of  cold  water  {bry.,  cupaf 
pcrf.,  opp.  ars.);  great  heat  in  head,  with  coldness  of  the  body 
cold  sensation  at  small  spot  on  forehead;  heat  intolerable  during 
the  hot  stage,  but  the  slightest  motion  of  the  ^bedclothes  causes 
chilliness;  urine  scanty,  brick-dust  sediment  ( Z^/c. );  sour,  offen- 
sive sweat,  like  mouldy  earth. 

Arsenicum  alb.— In  the  tertian  type  of  intermittents,  when  the 
paroxysms  are  either  incomplete,  or  else  well-marked  and  vio- 
lent, and  in  fevers  contracted  at  the  sea-shore  (gels.);  the  inter 
mission  is  never  clearly  defined;  the  paroxysnf^  appear  mostly 
in  the  afternoon,  and  may  anticipate  one  hour  every  alternate 
day;  they  sometimes  recur  every  fourteen  days;  after  abuse  of 
quinine;  sad,  tearful,  anxious  mood  {ign.,  jmls.);  great  rest- 
lessness; fear  of  death  (aconite);  great  weakness  and  prostra- 


(M 


I.ECTniEH  ox    IKViatS. 


tinn;  tlosiri'  to  litMli)\vii  {tniiicd);  Indulaflio,  vertigo,  niul  pnlo- 
iicss  of  MK't'  ami  lip.-*;  sallow,  rlny-colorcd  coinploxiun;  pain 
aii«l  (listL'ii.sioii  ill  tlu>  li'ft  hypochoiulriuiii;  intcuuu  Imniiiig 
l)aiiw  in  tlio  stoiuai-h  ami  pit  of  the  Htoiiiacli;  aversion  to  food; 
tonf^uo  fnrrt'tl  at  tlu»  edges,  with  red  streak  down  the  eenter,  and 
red  tip;  pidse  small,  weak  and  compressible;  sleepiness  the 
night  lii'fore  the  paroxysm  (ojjp.  ^/n/h/hc);  yawning  and  stretch- 
ing before  the  chill;  chill  irregularly  developed,  and  frequent 
ly  mixed  with  the  heat  (iiiixy,  internal  chill  with  external 
heat  anil  red  chetsks  (cdlc);  chill  ameliorated  by  external 
warmth  (opj).  f >/)/.<*,  <ini.,  ijx'o.,  puis.);  scarcely  any  thirst  dur- 
ing the  chill;  drinking  increases  the  chill  and  causes  vomiting; 
chillimss  and  shuddering  without  thirst,  worse  in  the  open  air; 
external  coldness,  with  cold,  clammy  sweat;  the  cold  stage  is 
frctpiently  absent,  the  hot  stage  predominating;  or,  the  chill 
and  heat  may  predominate,  with  little  or  no  sweat;  the  fever 
may  be  either  wanting  or  mixed  up  with  the  chill,  or  else  is  in- 
tense and  long -lasting;  hiccough  at  the  hour  Avhen  the  fever 
ought  to  hove  come;  great  restlessness  during  the  heat;  great 
thirst  for  cold  Avater;  wants  little  at  a  time,  but  often  {quinine, 
opp.  hri/.);  l)urning  in  the  stomach  and  vomiting;  great  rest- 
lessness during  the  heat;  cold,  clammy  sweat,  with  excessive 
thirst  for  large  quantities  of  water;  great  weakness  and  pros- 
tration after  the  paroxysm. 

Belladonna.— In  quotidian  and  congestive  intermittents,  in 
plethoric  lymphatic  constitutions;  masked  intermittents  associ- 
ated with  severe  neuralgia;  great  irritability;  whining  mood; 
the  hot  stage  predominates;  chill  commences  in  the  scrobiculus 
cordis;  shivering  running  down  the  back,  and  terminating  in  the 
pit  of  the  stomach;  chilliness  in  the  arms;  seldom  any  thirst; 
the  face  is  pale  when  lying  down,  but  red  when  sitting  up  (opp. 
aconifc);  intense  burning  heat  inside  and  out;  averse  to  uncov- 
ering; sensitive  to  light  and  noise;  throbbing  carotids  (glon.); 
bui'sting  headache;  very  red  face;  eruption  in  the  corners  of 
the  mouth  or  on  the  lips;  choking  s.snsation  in  the  throat,  with 
dryness  of  the  iiiouth ;  tongue  is  red  and  dry  along  the  edges,  and 
white  in  the  center;  the  papillro  are  bright  and  prominent  {tari. 
emci.);  sweat  starting  at  the  feet  and  passing  upwards;  sweat  on 
covered  parts  only;  sweat  stains  the  linen  yellow;  the  sweat  stage 
may  be  entirely  M-anting. 


k^U-,,. ,- 


id  pnle- 
11 ;  pain 
burning 
to  food; 
[UiT,  and 
lOHW    tlio 
Htretch- 
re(|Uonb 
jxtornnl 
external 
rbt  tlur- 
iiuiting; 
)pen  air; 
stage   is 
;he  chill 
lie  fever 
lae  is  in- 
lie  fever 
at;  great 
'quinine, 
eat  rest- 
axcessive 
nd  pros- 

itents,  in 
ts  asBoci- 
ig  mood; 
robiculus 
ng  in  the 
ly  thirst; 
up  (opp. 
to  uncov- 
3  (glon.); 
orners  of 
roat,  with 
Klges,  and 
ent  {tart. 
sweat  on 
veat  stage 


LE.VDINd    INDIiATlONH. 


65 


Hrynilia.  in  intfrmittt'iitHnftcrgi'ttiii^'  wnt  (  rnlr.  carh.,  v/iiin); 
^vitli  tliirht  ill  nil  tiio  ntiigcs;  aiitii-ipiiliiig  ty|i»>;  t[n\  patient  Ih 
vury  irritalilc,  andj-anily  angori'd  (omw.);  appn  luMiHivo;  dri)iinis 
about  buHino.ss  ami  huusjliold  alliiiis;  con.stipHtioii;  wtools  dry 
and  hard  as  if  burnt;  gastric  syiiii)t()niH|)rt'(loniinato  (a///,  rrntl.); 
jiationt  has  to  move  frequently;  the  parts  feel  mm){(irniv<i); 
feels  best  when  lying  on  painful  side  (piih.);  stretching  and 
drawing  in  the  limbs;  desire  to  lie  down  during  the  paroxysm; 
sitting  ui)  causes  nausea  and  vomiting;  vumiting,  lirst  of  bile, 
then  of  fluids  (o])p.  luit.  mm: ). 

The  chill  predominates,  and  is  creeping  rather  than  shaking 
in  character.  Violent  thr()l)bing  heailacho,  as  if  the  head  would 
Imrst,  beftire  the  chill;  chill  begins  in  the  lips,  tips  of  fingers 
and  toes;  pain,  as  if  dislocated,  in  the  wrist  and  ankle  (»•//««, 
nila);  violent,  dry,  racking  cough  during  the  chill,  continuing 
through  the  heat,  with  stitching  pains;  patient  holds  the  ster- 
num  when  coughing;  stitches  in  the  spleen  (rcdnolltns);  great 
thirst  feu- large  quantities  of  water,  with  cough,  during  the  hot 
stage;  heat  on  moving  (oi)p. bell, mix);  burning  internal  heat, 
as  if  molten  lead  were  running  through  the  blood-vessels  (ars., 
rinis);  profuse,  sour,  oily  sweat  (c/t ma);  sweat  on  single  parts 
only,  or  on  side  on  which  patient  lies;  sweat  from  the  least  exer- 
tion; all  the  symptoms  are  worse  in  a  warm  room  and  better  in 
the  open  air. 

Cactus.— In  quotidian  interraittents  when  the  intermission  is 
complete  and  the  paroxysm  returns  at  11  a.  m.  or  11  v.  m.;  re- 
lapses from  exposure  to  the  sun's  rays;  prolonged  chill  not  re- 
lieved by  covering  (amnea);  coldness  of  the  back,  and  icy 
coldness  of  the  hands;  long-lasting  heat  with  dyspncea  and  short- 
ness of  breath  (ars.,  jjhos.);  flushes  in  the  face;  insupportable 
heat  in  the  abdomen;  lancinating  pains  in  the  heart  (spig.); 
sense  of  constriction  in  parts;  profuse  sweat  with  unquenchable 
thirst. 

Calearea  carb.—In  leucophlegmatic  temperaments;  large  bel- 
lied individuals  and  persons  who  take  cold  easily;  chronic  inter- 
mittents;  the  intermission  is  never  very  clear;  paroxysms  at  2 
p.  M.;  thirst  during  the  chill;  chill  begins  at  the  pit  of  the  stom- 
ach with  spasms,  or  n  fixed,  cold,  agonizing  weight;  heat  without 
thirst;  fever  at  11  a.  m.,  without  thirst  and  without  previous 
chill;   heat   worse    from  bathing  (opp.  fluoric  acid);  profuse 


'.%-' 


m 


LECTUllES  ON   lEVEltiJ. 


iiiil^ 


III 


m. 


SAveat  in  the  morning  nnd  on  the  slightest  exertion;  sweat  with- 
out tliirst;  shortness  of  breath  on  going  up  stairs  («rs. );  un- 
digested stools  {cliin(i);  alternate  constipation  and  diarrhea. 

i'aiiiplior. — Specially  useful  in  pernicious  malarial  fevers;  con- 
gestive chills;  long-lasting,  shaking  chills;  coldness  of  the  skin; 
icy  coldness  of  the  whole  body  {fdlxic. ) ;  deathly  paleness  of  the 
face  {verut.  all).);  cold,  trembling  tongue;  heat,  with  disten- 
sion of  the  veins;  increased  by  motion  (opp.  caps.);  cold,  ex- 
liausling,  viscous  sweat;  great  anxiety,  weakness,  and  exhaustion; 
extreme  sensibility  to  cold  air  {iniji). 

Canchalagua. — In  spring  intermittents  that  are  ushered  in 
with  a  severe  chill;  the  skin  of  the  hands  and  feet  after  the 
sweat  resembles  a  washerwoman's  skin;  patient  has  a  good  ap- 
jjetite  during  the  intermission. 

Capsicum. — Midsummer  intermittents  in  stout,  phlegmatic 
individuals;  the  intermission  is  tolerably  clear;  there  is  thirst 
before  and  during  the  chill;  shuddering  after  chunking;  the  chill 
commences  between  the  shoulders,  and  is  relieved  by  putting 
something  hot  to  the  back;  general  coldness  of  the  body;  intol- 
erance of  noise;  no  thirst  during  the  heat;  acrid  sweat;  sweat 
without  thirst;  burning  mucous  diarrhea;  appetite  but  little 
impaired;  ears  and  tip  of  nose  red  and  hot  towards  evening;  all 
stages  relieved  by  motion. 

Carlio  veg. — In  pernicious  malarial  fevers;  irregular  parox- 
ysms. Great  prostration  during  the  intermission;  bloating  of 
stomach  between  the  paroxysms.  Toothache,  headache,  and 
pain  in  the  limbs  precede  the  paroxysm ;  thirst  only  during  the 
chill  {{(jn.);  icy  oldness  of  the  body  and  cold  breath;  coldness 
of  the  tongue;  coldness  of  the  knees,  even  in  bed  {(tpis);  chill 
beginning  in  the  left  hand;  (in  right  arm,  mere);  left  sided  chill 
(cansticuni);  heat  without  thirst;  loquacity  during  the  heat 
{podo.);  oppressed  respiration  {(qns);  desire  to  be  fanned; 
the  fever  is  succeeded  by  severe  headache;  profuse  soui*  sweat; 
sweat  even  when  eating  {carbo  an.);  easy  to  sweat  and  easy  to 
chill;  spleen  swollen  and  painful;  livid  spots  on  face;  foetid 
breath;  after  abuse  of  quinine. 

Cedroil. — In  quotidian  and  tertian  intermittents  in  low  marshy 
regions,    the    chill    predominates    and   the  paroxysms    recur 


<5 
t] 
V| 


iSSS^ 


LEADING   INDICATIONS. 


67 


i;  sweat  with- 
8  («rs.);  uu- 
l  diarrhea. 

fl,l  fevers;  con- 
es of  the  skin; 
»aleness  of  the 
,,  with  disten- 
^)s. ) ;  cold,  ex- 
iid  exhaustion; 

ire  ushered  in 
feet  after  tlie 
las  a  good  ap- 

ut,  phlegmatic 
there  is  thirst 
ikiug;  the  chill 
ved  by  putting 
ihebody;  intol- 
A  sweat;  sweat 
jetite  but  little 
rds  evening;  all 

rregular  parox- 
)n;    bloating  of 

headache,  and 
only  during  the 
n-eath;  coldness 
jed  (apis);  chill 
;  left  sided  chill 
luring  the   heat 

to  be  fanned; 
)fuse  sour  sweat; 
weat  and  easy  to 

on  face;    foetid 

its  in  low  marshy 
jaroxysms    recur 


with  clock-like  regularity  (nranea)',  chill  preceded  by  great 
mental  depression  and  headache;  chill  without  thirst  at  3  a. 
M.  or  3  p.  M. ;  icy  coldness  of  the  hands  and  the  tip  of  the  nose; 
cramps  with  tearing  pains  in  upi)er  extremities;  heat  with  thirst 
for  warm  drinks;  entire  body  feels  numb;  sweat  with  thirst;  dry 
heat  followed  by  profuse  perspiration;  general  malaise  and  de- 
bility during  the  intermission. 

Chamomilla. — In  children  and  nervous  adults;  gastric  com- 
plications; the  patient  is  very  irritable  and  restless  (bry.);  ex- 
cessive sensitiveness  to  pain  (c.oj}'ca);  thirst  during  the  heat  and 
sweat,  none  during  the  chill;  chill  usually  slight,  only  on  ante- 
rior portion  of  the  body;  shivering  of  single  parts,  and  heat  of 
others;  one  cheek  red  and  the  other  pale;  sour  sweat,  during 
sleep,  mostly  on  the  head  with  smarting  of  the  skin  {caps.);  yel- 
low coated  tongue;  tongue  white  at  the  sides  and  red  in  the  mid- 
dle (opp.  lart  emet);  nauaea  and  vomiting  of  bile,  and  diarrhea; 
frequent  emissions  of  large  qui'.ntities  of  pale  urine. 

Cinchona. — The  chill  is  preceded  by  nausea,  headache,  hun- 
ger, anguish,  palpitation  of  the  heart  and  great  thirst.  Chilli- 
ness after  every  drink  (caps.,  ctipat  pcrf. ) ;  general  shaking,  vio- 
lent chill  without  thirst,  increased  by  drinking;  chills  alternat- 
ing with  heat,  skin  cold  and  blue  (nnx);  thirst  before  the  heat, 
none  during  the  heat;  general  heat  with  swollen  veins;  cheeks, 
though  of  natural  heat  are  red,  and  feel  hot  to  the  patient;  ca- 
nine hunger,  or  else  aversion  to  food;  great  thirst  during  the 
sweat;  sweating  during  sleep  or  on  being  covered;  great  lassi- 
tude and  exhausting  sweats  during  the  intermission;  ringing  in 
the  ears,  and  a  feeling  as  if  the  head  were  enlarged  {calc,  mix); 
saffron  yellow  color  of  the  skin;  the  patient  looks  jaundiced; 
anaemic  and  cachectic  apy^^arance;  spleen  and  liver  swollen, 
and  painful  on  pressure;  urine  scanty  with  yellow  or  brick-dust 
sediment;  all  symptoms  are  aggravated  by  motion  or  the  slightest 
effort.  ^ 

Cimex. — The  chill  begins  with  clenching  of  the  hands  and 
violent  rage;  pain,  particularly  in  the  knee  joints,  during  the 
chill,  as  if  the  tendons  were  too  short;  thirst;  can  drink  before 
the  paroxysm  begins,  but  during  the  paroxysm  drinking  causes 
violent  headache  and  a  gagging  cough  with  dyspnoea. 

Thirst  instead  of  fever  after  the  chill;  is  obliged  to  urinate 


11  17 


i  W  'i 


68 


LECTUnES  ON  FEVERS. 


after  drinkinfi;  heat  with  pressure  and  gagging  in  the  oesopha- 
mis;  ravenous  hunger  after  the  heat;  musty  sweat,  which  re- 
lieves,  without  thirst;  thirst  during  the  intermission. 

Ciiia.-In  quotidian  intermittents  of  scrofulous  children;  the 
intermission  is  never  very  clear,  and  warm  symptoms  predomi- 
nate; frequent  tickling  of  the  nose  (p/ios.  acid);  clean  tongue; 
chill  ascending  from  the  trunk  to  the  head,  with  hunger  but  no 
thirst;  heat  with  redness  of  the  cheeks,  without  thirst,  aft^r 
sleep;  sweat  usually  slight,  at  times  cold,  especially  on  the 
hands,  forehead  and  nose. 

Cocculus.— In  children  and  hysteric  females  {tanmtiila);  with 
spasmodic  symptoms;  severe  colic  duringthe  chill  (r«aflfu.2)/*os.); 
aversion  to  sour  things  (opp.  ant  crud.);  obstinate  constipation; 
nil  symptoms  aggravated  by  eating  or  drinking. 

Cornus  florida.— In  obstinate  intermittents;  the  paroxysm 
is  preceded  for  days  by  sleepiness,  sluggish  flow  of  ideas,  and 
headache;  during  the  chill  the  skin  is  cold  and  clammy;  nausea 
and  acidity  of  the  stomach;  throbbing  headache  during  the 
fever;  during  the  intermission  there  is  debility,  loss  of  appetite 
and  painful  bilious  or  watery  diarrhea. 

Elateriiim.— When  urticaria  appears  after  suppressed  inter- 
mittents; the  itching  is  relieved  by  scratching  {ign.  opp.  rhus). 
Eupatorium  perf— In  double  tertians,  and  in  intermittents 
that  tend  to  run  into  remittents;  paroxysms  end  with  vomiting 
of  bile;  hectic  cough  from  suppressed  intermittents  {cinch.);  the 
intermission  is  apt  to  be  imperfect,  and  may  be  attended  by  a 
loose  cough;  bone  pains  in  every  stage;  worse  on  the  morning 
of  one  day  and  the  afternoon  of  the  next;  skin  sallow;  tongue 
coated  white  or  yellow;  morning  diarrhea,  {podo);  great 
thirst,  vomiting  and  aching  pains  in  the  extremities  before  the 
chill; 'soreness  of  the  eyeballs;  chill  7  to  9  A.  M.;  chill  spreads 
from'  the  back;  thirst,  vomiting  and  pains  in  the  back  and 
limbs  as  if  bruised  or  beaten  (am.);  moaning  during  the  chill; 
chill  followed  by  heat  without  perspiration;  nausea  and  vomit- 
ing at  the  close  of  the  chill,  aggravated  by  drinking;  thirst  dur- 
ing the  heat,  with  bitter  vomiting,  headache,  and  pain  in  the 
limbs;  shivering  during  the  heat;  sweat  may  be  scanty  or 
absent;  it  is  slight  or  wanting  when  the  chill  is  severe;  or  vice 


-i|)l!»iH»!M.!l 


LEADING   INDICATIONS. 


69 


oesopha- 
wLich  re- 

dren;  the 
predomi- 
n tongue; 
er  but  no 
lirst,  after 
y  on  the 

Ilia) ;  with 
jn.  phos. ) ; 
istipation; 

paroxysm 
ideas,  and 
ly;  nausea 
luring  the 
3f  appetite 

jsed  inter- 
)pp.  rhns). 

termittents 
h  vomiting 
',inch.)',  the 
mded  by  a 
e  morning 
)w;  tongue 
io);  great 
before  the 
ill  spreads 
>  back  and 
g  the  chill; 
and  vomit- 
thirst  dxir- 
lain  in  the 
scanty  or 
jre;  or  vice 


versa;  perspiration  increases  the  headache,  but  relieves  all  the 
other  i^ains,  {naf.  mm:). 

Eiipatoriiini  piiri).— In  tertian  intermittents;  during  the  in- 
termission, vertigo  Avith  sensation  of  falling  to  the  left;  desire 
for  cold  acid  drinks,  (calc.  sulphide;)  tongue  coated  and  brown 
in  the  center;  deep,  dull  pains  in  the  kidneys  {brrh.);  pains  in 
the  arms  and  legs  before  the  chill;  chill  begins  in  the  lumbar 
region  {lack.);  severe  pains  in  the  bones  with  numbness  of  the 
legs;  frontal  headache;  bluenessof  the  lips  and  nails  {mix,)  vio- 
lent shaking  with  little  coldness;  thirst  during  the  hot  stage; 
long  lasting  heat  followed  by  hunger;  sweat  mostly  on  the 
upper  part  of  the  body,  and  usually  slight. 

Ferruin.— In  protracted  intermittents  after  the  abuse  of  qui- 
nine, when  there  are  anemia,  debility  and  great  muscular  weak- 
ness; extreme  paleness  of  the  face,  and  of  the  mucous  membrane 
of  the  lips  and  mouth;  ague-cake,  {ceanothus,  herheris  viilg.); 
vomiting  as  the  chill  appears;  thirst  with  the  chill;  hands  and 
feet  cold  and  numb;  no  thirst  during  the  hotstage;  rush  of  blood 
to  the  head  with  flushes  of  heat  in  the  face,  hot  flushes,  {kali 
carb.;)  red  cheeks;  sensations  of  heat  ali  over  the  body,  which  is 
cold  to  the  touch  (opp.  baryta  carb.)  ;heat  in  palms  of  the  hands 
and  soles  of  the  feet;  profuse,  long-lasting,  debilitating  sweat; 
sweat,  clammy,  strong  smelling,  and  stains  the  linen  yellow- 
all  the  symptoms  are  aggravated  by  sweating  (opp.  nat  mur.). 

Oelseiniuiii.— In  recent  uncomplicated  quotidian  intermit- 
ents,  occurring  in  children  and  nervous  yt)ung  i)eople;  the  par- 
oxysm usually  begins  in  the  evening,  though  the  fever  may  re- 
cur alone  at  10  A.  m.  ;  the  intermission  may  be  short  or  wanting, 
and  there  is  great  muscular  prostration;  the  chill  begins  in  the 
hands  and  feet,  and  is  unattended  by  thirst;  the  fever  may  be 
intense  and  burning,  and  accompanied  by  a  sensation  of  fall- 
ing, especially  in  children;  there  is  great  mental  anxiety,  red- 
ness of  the  face  and  nervous  restlessness  during  the  hot  stage; 
the  sAveat  is  apt  to  be  profuse,  and  relieves  the  pain  {nat.  mur.', 
opp.  fcrrum. ) ;  sweat  most  profuse  on  the  genitals. 

Calcium  Sulphide.— After  abuse  of  mercury  or  potassium 
iodide;  the  patient  is  very  sensitive  to  the  cool  air;  fainting 
from  the  slightest  pains;  urticaria  before  and  during  the  chill- 
'Violent  shaking  chill  every  morning  without  heat;  burning  heat 


iHV*-rTlfiin-inTiifiia 


wth0 


LECTU11E9  ON   I'EVEBS. 

trroius  and  inside  o£  thighs. 

"  X       ,'        Th«  intermission  is  complete;  yawnmg,  stretclimg, 
Ignatia-lhe  intermissio,  J  ^^  the  arms; 

,,Uhudder.ng^b^^^^^^^^^^ 

ing  chill  yith  reaness  „tities  of  water,  only  during 

one  Bideof  the  face  «U.ulbuin.ng(am^cto^^^^^^ 

the  whole  ^.y  *--8  "a^ltwlveLlduriBgthe 

usually  slight,  most  on  the  face. 

driaml  ague-cake.  i„tormittente,  andin 

cases  that  have  oeen  ^  /,.„;«  V  the  wroxysm  is  preceded 

Up.»eav.edhye™.md^^^^^^^ 

by  yawmng,  ''^''-'""f  »  the  stages;  the  prostra- 

Mververy  *"■,""'"'"'' ""^^Ttwhill  is  aggravated  by  exter- 
ti„n  is  greatest  durmgthe  chill,  '^^^  ™  '^"fj;^^  by  driuking, 

-«■■•*  ^r?  ■  :K-r  a^"-^'"s-  -'^  ■^''  "^f - 

(opp.  '-'f 'f  1"{;"'"S:  "iterate  coldness aodpaleaess  o£  the 
■     ir  "ii'-»?  ^^-  '*-•  *-"'*  "^'"'^  "^''"'''  '""^ 

after  sleep;  throat  IS  veryjnsu^^^^^^^  ^ 

the  chill  P-f-;-^^^^^^^^^  of  a  stove,  and  by  being 

purp.,r,  chill  ^^^/f^^JX^^^^^^g  the  bedclothes,  {nux  vom.); 
firmly  held;  ^^"^^""Sy^^''  ,  ,iL„in„  foom  place  to  place;, 
chill  and  heat  alternating,  and  changing  trom  p 


LEADING   INDICATIONS. 


71 


rinks;  Bleep- 
[{nat.mnr.); 
d  by  motion; 
in   perinenni, 

ig,  stretcliing, 
in  the  arms; 
r.  aciV^ ;  sliak- 
)ved  by  exter- 
ir,  only  during 
t  internal  heat; 
;  urticaria  over 
ig,  relieved  by 
3red  during  the 
g  stage;  sweat 

lis;  emaciation; 
iarrhea  during 
)le£thypochon- 

mittents,  and  in 
and  arsenic;  re- 
:y8m  is  preceded 
intermission  is 
ges;  the  prostra- 
i-avatedby  exter- 
aed  by  drinking, 
;,  and  dry,  hack- 
id  paleness  o£  the 
symptoms  worse 

•unkards  and  in 
al  spring  attacks 
iptoms  are  worse 
•h;  filiform  i)ulse; 
of  the  back,  (eup. 
)ve,  and  by  being 
)thes,  {mix  vom.)', 
im  place  to  i)lace',. 


gi-o.it  talkativeness  during  tlio  lieat,  {manim  ver.)  which  is  gen- 
erally irrog.ilar;  heat  with  d.' lire  to  uncover;  cyanosis  durin- 
the  fever:  perspiration  in  axilla  smelling  like  garlic;  profuse 
sweat  wiiich  affords  relief. 

Lycopodium.—Iu  quotidian  and  tertian  intermittents;  irreg- 
ular types;  great  fear  (.f  being  left  alone  (opp.  cmcA.);  yellow- 
ish-gray color  of  the  face  (ars.);  abdominal  flatulence;  sour 
eructations  and  sour  vomiting;  vesicles  on  the  tongue;  obstinate 
constipation;  increased  micturition;  paroxysm  at  G  to  7  v.  m.- 
yawning  and  nausea  before  the  chill;  chill  starting  from  the 
back;  shaking  chill,  great  coldness  even  in  bed,  as  if  lying  on 
ice;  left  sided  chill  (carho.  vaj.,  opp.  hry.);  nnmh,  icy  cold  hands 
and  feet;  cutis  anserina;  chilliness  in  the  morning,  followed  by 
great  heat;  sour  vomiting  between  the  chill  and  the  heat;  sour 
vomiting  during  the  hot  str-e;  sore,  pressive  pain  in  tlie  region 
of  the  hver;  burning  as  from  glowing  coals  between  the  scapu- 
la; profuse  sour  sweat  on  the  body;  perspiration  immediately 
after  the  chill  {canst);  thirst  after  the  sweat. 

Menyantkes.— In  irregular  intermitte^^ts  when  the  cold  stage 
predominates-  quartan  fevers;  ravenous  hunger;  great  desire 
for  meat  (opp.  salph.,  arnica);  coldness  of  the  distal  parts; 
coldness  in  the  abdomen,  aggi-avated  by  pressure;  the  hands  and 
feet  are  icy  cold,  the  rest  of  the  body  warm;  great  heat  without 
thirst;  flushes  of  heat  with  hot  ears  and  cheeks;  sweat  contin- 
uing all  night. 

Xatrum  mur.— In  quotidian  intermittents  in  new  districts; 
after  abuse  of  quinine;  the  intermission  is  never  very  clear; 
suUow  complexion;  stitches  in  the  hepatic  region  between  the 
paroxysms;  loss  of  appetite;  bitter  taste  {bry.,2mls.);  dry,  white- 
coated  tongue;  feeling  as  of  a  hair  on  the  tongue  (kali  hkh.); 
herpes  on  the  lips,  {ars.);  ulceration  of  the  corners  of  the  mouth- 
frequent  vomiting  of  water  and  mucus  before  the  chill;  chill 
from  10  to  11  A.  M.;  long-lasting,  violent  chill  with  blueness  of 
the  hps  and  nails  {mm);  thirst  for  large  quantities  of  water 
and  often  {hnj.);  prolonged  heat  with  thirst;  hammering  frontal 
headache;  excessive  weakness  during  the  heat;  red  sandy  sedi- 
ment in  the  urine  ( Z»/c. ) ;  cutting  in  the  urethra  after  micturi- 
tion; profuse  sweat  which  relieves  all  the  pains  except  the  head- 
ache {evpai.  pcrf.). 


1    !' 

1    ''• 

r 

r 
i 
1 

LECTUliES   UN    FKVKllS. 

Nux  .«.ni(.a.-Ax>ticipating  intermitKn^s  in  ^'J^, 
incUviduals;  inoguh.r  paroxysmB.  at  night  or  eavlj  mm  i^^, 
"^  no  and  bilio^sympton.  pvedmuinat.;    ongue  -';^-^    ; 

ri:;!  the  spi..  extrenutios  feel  as  j£  1-;^^^^^^ 
onset  of  tlio  chill;  heat  or  sweat,  occasionally  be  oie  the  clu  i , 
^^dlillwith  bluenessof  tl.  face  -^  ^^  ^^^l^^  ^   ^ 
sacrum  during  the  chill;  severe,  long-lasting  chill,     "^/^*;*;^^^ 
^™th;  congestive  chills;  gre.vt  thirst,  -1-;^^;^  -  ^ -; 
daviiiL'  the  heat;  loug-lasting,  burning  heat,  yet  can  neitlier  nn 
t:  t^isLwithoi^  feeling  chilly;  ^^^^YT::^^^^^ 
chest  and  vomiting  during  hot  stage;  ---^^^  ^^^^ ^'^^ ^ovh  ^ 
fuse  sweat  after  the  severest  paroxysn.s;  ^^^^^^j^^ 
the  bedclothes;  extreme  sensitiveness  to  the  cold  air  (ccmi     , 

cocc). 

On..«..-I.  especially  *P--:  ^^^IC^ 

gestive  chill. 

Poaophvllum.-In  bilious  temperaments;   loss  of  appetite; 

the  iver  an    spleen    se^er  ^^^^  ^^^.^^.  ^^^^^^ 

^^^:^\^t^^e^^o  thirst  anringihechi    ; 

Wwith  excessive  thirst,  commencing  -- ;  "l^^'  ^^^f^^ 
vi..lent  pains  in  the  head;  profuse  sweat;  sleeps  duiing  the 

sweat  (aj)/s). 

rolvBorus.-In  stubborn  quotidian  intermittents;  the  inter- 

Sdidl  headache  and  jaundiced  skin;  numb  sensations  after 

and  flushed;  slight  but  long-lasting  sweat  without  thirst,  rarely 
cf  service  in  autumnal  intermittents. 


LEADING   INDICATIONS. 


73 


thin,    slender 
uly  morning; 
i  coated,  wliiU' 
;  oonstipa^on; 
ra]}Z(Hl  ut  the 
[ore  the  chill; 
Is;  pain  in  the 
1,  not  relieved 
•ially  for  beer, 
!an  neither  nn- 
•ertigo,  pain  in 
)ut  tliirst;  pro- 
ess  on  moving 
Id  air  {camph., 

id  f)ld  persons; 
breathing;  face 
dremities;  con- 


3SS  of  appetite; 
;  tongiie  coated 
;  morning  diar- 
iii  the  region  of 
itnot  during,  the 
5  chill;  dull  ach- 
during  tiie  chill; 
luring  the  chill; 
eeps  during  the 

ttents;  the  inter- 
y  in  the  morning; 
»dominal  viscera, 
sensations  after 
ar region  (cops.); 
ng  fever;  inertia 
er;  the  face  is  hot 
lout  thirst;  rarely 


Pulsatilla.— Adapted  to  women  and  children,  and  to  individ- 
uals of  mild,  sensitive  temperament;  irregular  types;  quartan 
intermittents;  relapses  from  dietetic  errors;   recurring  every 
fourteen  days;  all  stages  of  paroxysm  are  mild  anil  frequently 
mixed  up;  constant  chilliness  and  headache  during  the  intermis- 
sion; changing  symptoms;  tongue  tliickly  coated,  white  or  yel- 
low,  and  covered  with  a  teimcicms  mucus;  bad  taste  in  the  mouth 
in  tlie  morning;  disgust  for  fat  food  (opp.  mix);  mucous  diar- 
rhea; profuse  watery  urine;  diarrhea  and  drowsiness  the  day 
before  tlie  paroxysm;  chill  at  4  r.  m.,  without  thirst;  one-sided 
coldness;  chilliness  (jvcr  the  abdomen  extending  around  to  the 
back;  acidity  of  the  stomach,  and  vomiting  of  mucus  and  bile; 
chill  and  heat  simultaneous  (ar.s.);  dry  heat  of  the  body  with 
distended  veins,  and  burning  hands;  thirst  only  during  the  heat; 
external  warmth  is  intolerable  {sciua);  desires  to  bo  unco^ered 
{apis);  feels  for  cool  places  in  the  bed;  one-sided  sweat,  mostly 
on  the  left  side;  talkativeness  when  sleeping  during  the  sweat; 
chlorotic  states;  menstrual  irregularities. 

Quinine.— (C/jm/»w    sulph.)   In  tertian  intermittents  when 
the  paroxysms  recur  at  the  same  hour;  and  in  quotidian  inter- 
mitteuts  that  anticipate  two  hours  everyday;  the  intermissions 
are  clearly  defined;  there  is  great  debility,  prostration  and  thirst 
between  the  paroxysms;  the  urine  is  fatty  and  deposits  a  straw 
yellow  or  brick-dust  sediment;  pain  in  the  region  of  the  liver 
and  spleen;  ringing  in  the  ears;  dizziness  and  enlarged  feeling 
m  the  head;  pain  in  the  dorsal  vertebrje  on  pressure,  during  the 
paroxysm;  decided  shaking  chill  with  thirst  at  3  p.  m.;  shaking 
chill  with  severe  pains  in  the  left  hypochondrium;  chill  with 
blueness  of  the  lips  and  nails  {mix);  heat,  with  great  thirst; 
general  heat,  with  redness  of  the  face;  enlargement  of  the  veins 
of  the  legs  and  arms;  delirium  during  the  hot  stage;  heat  grad- 
ually passes  into  sweat;  violent  heat,  with  frequent  yawning 
and  sneezing,  followed  by  copious  sweat;  sweat,  with  thirst; 
profuse  sweat  during  perfect  quiet;  sweat  relieves  all  other 
symptoms,  but  aggravates  the  headache;  drinking  is  generally 
grateful  and  affords  relief. 

Rhus  tox.— In  quotidian  intermittents  which  tend  to  run  into 
remittents;  relapses  from  getting  wet;  evening  paroxysms;  burn- 
ing in  the  eyes ;  yawning  and  stretching,  and  a  feeling  in  the  maxil- 


---^■atUNMMMNWMi 


■iwmiifff'KiiiHinji-iiW^  ,. 


74 


LECTUllES   ON   FEVEllH. 


lary  joint  as  if  sprained,  l)ofore  the  paroxysm;  dry,  teasing  cough 
before  and  during  tlie  cliill  {ruiur.r);  none  during  the  heat; 
(during  the  heat,  acouih);  tongue  coated  wliite  with  red,  dry, 
triangular  tip;  stretching  an.l  pain  in  the  liiabs;  chill  aggravated 
by  drinking;  onstant  chill,  as  if  cold  water  was  poured  over 
him  (led.)',  feeling  as  if  the  blood  was  lunning  cold  through  the 
vessels  (opp.  <«/•«.);  alternately  red  and  pale  face;  fever  may 
either  precede  or  succeed  the  chill;  excessive  heat  as  from  hot 
water  running  through  the  vessels;  great  restlessness,  constantly 
changing  position  («rs.,  opp.  hvy.);  thirst  for  cold  water  or  cold 
milk-  drinks  little  at  a  time  but  often;  profuse  sour  morning 
sweats;  sweat  even  during  the  heat;  sleep  during  the  sweat; 
urticaria  which  passes  off  with  the  sweat, 

Sabadilla.— The  chill  predominates;  chill  always  passes  from 
below  upwards  (opp.  rcra/.);  dry,  spasmodic  cough  during  the 
chill,  with  tearing  in  the  limbs;  paroxysms  recur  at  the  same 
hour  ( rrmw.,  crrfro/0 ;  constant  chilliness  during  the  intermission ; 

alternate  attacks  of  hunger  and  loathing  of  food. 

SambllCUS.— When  the  perspiration  continues  through  the 
intermission;  profuse  sweat  when  awake,  dry  heat  during  sleep; 
deep,  dry,  racking  cough,  for  half  an  hour  before  the  chill. 

Sepia.-In  chronic  cases;  intermittents  in  pregnant  and  nurs- 
ing women;  monthly  paroxysms;  perfect  absence  of  thirst  {puis. ) ; 
coldness  begins  in  the  feet  and  passes  upwards;  chilliness  from 
motion  (nux);  sensation  as  if  the  limbs  and  fingers  were  dead; 
icy  cold  and  damp  feet  all  day,  like  standing  in  cold  water;  ex- 
ternal warmth  unbearable  {puis.);  flushes  of  heat  {snlph.);  ver- 
tigo; sensation  as  if  hot  water  was  being  poured  over  him,  dur- 
ing the  heat;  profuse  sweat  in  the  morning  after  awaking. 

Sulphur.— In  chronic  cases  and  in  chronic  malarial  cachexia,- 
great  prostration  after  every  paroxysm  {ars.);  with  thirst  for 
beer-  diarrhea  in  the  early  morning;  chill  begins  in  toes  or  sa- 
crum; icy  coldness  of  the  genitals;  dry  skin  with  heat  and  burn- 
ing  in  the  soles  of  the  feet  during  the  fever;  siveat  from  the  least 
exertion  {mere);  profuse  sweat  at  night,  with  restlessness;  sul- 
phur is  often  serviceable  to  arouse  the  reactive  power  of  the 
system. 

Teratrum  alb.— In  pernicious    malarial  fevers;  children's 


PALLIATIVE  AND   DIETETIC  TUEATMENT. 


75 


casing  cough 
ing  the  hoiit; 
ith  red,  dry, 
11  aggravated 

poured  »)Vor 
I  thrcnigh  the 
3;  fovcr  may 

na  from  hot 
SB,  constantly 
water  or  cold 
!our  morning 
ig  the  sweat; 

s  passes  from 
;h  during  the 
•  at  the  same 
intermission; 

1  through  the 
during  sleep; 
the  chill. 

lant  and  nurs- 
thirst(pM?s.); 
hilliness  from 
3rs  were  dead; 
ild  water;  ex- 
(snlph.);  ver- 
)ver  him,  dur- 
iwaking. 

arial  cachexia; 
with  thirst  for 

in  toes  or  sa- 
leat  and  burn- 
f rom  the  least 
stlessness;  sut 

power  of  the 

rs;   children's 


intermittents,  when  the  paroxysm  begins  at  0  A.  M. ;  severe  long- 
lasting  chill;  chill  with  coldness  and  thirst;  profuse  cold  sweat, 
with  deathly  paleness  of  the  face;  desire  for  cold  drinks;  groat 
exhaustion  during  the  intermission. 

TllEATMKNT   FOU   THE   SEQUELS. 

Merc,  hin-iod.— For  enlarged  spleen.  It  may  bo  given  inter- 
nally from  the  2nd  to  the  Gth  trit,  and  also  used  as  an  ointment, 
of  five  per  cent,  strength,  externally.  . 

Phosphorus  for  deranged  liver. 

Chelidoniiini  for  obstinate  neuralgia  of  the  fifth  neno,  ofter 
masked  intermittents. 
Arsenicum  and  Natrum  Mur.  for  chronic  malarial  cachexia. 

Ferruni  or  Arseniafe  of  Iron  for  anremia  and  debility  before 
the  occurrence  of  cedema;  anti  Pulsatilla  when  chlorosis  and. 
hydraemia  have  been  induced. 

PALLIATIVE   AND   DIETETIC   TREATMENT. 

During  the  intermission  a  nutritious  diet  should  be  indulged 
in.  Meat  essence  or  beef  tea,  tender  meat,  milk,  and  fre- 
quently wine  may  be  taken. 

When  gastric  irritability  continues  during  the  intermission,, 
benefit  will  accrue  from  the  use  of  milk  or  beef  tea  and  pepsin 
enemas.  At  the  onset  of  the  paroxysm  the  patient  should  take 
to  the  bed,  and  abstain  from  all  manner  of  food  until  it  is  over. 
During  the  stage  of  chill  relief  is  frequently  experienced 
from  galvanism  applied  to  the  spine.  Too  much  covering  is 
generally  burdensome,  and  should  not  be  allowed.  Should  this 
stage  be  protracted,  or  the  vital  powers  become  weakened,  stim- 
ulants and  external  warm  applications  must  be  resorted  to.  As. 
the  hot  stage  approaches  the  bed-covering  may  be  gradually  re- 
moved, and  the  body  frequently  sponged  with  tepid  water  if  the 
heat  is  very  great.  During  the  sweat  stage  allow  the  patient  to 
rest;  wipe  away  the  sweat  with  warm  cloths,  and  change  the  linea 
when  the  sweat  is  excessive. 

Use  stimulants  whenever  there  is  a  tendency  to  collapse  in 
debilitated  subjects.  But  unless  specially  needed  all  alcoholia 
beverages  should  be  strictly  avoided. 


: 

41 


:i 


ii 


LECTFRE  V. 

Simple  Reiiiltteiit  Fever. 

I  filinll  invito  your  nttenticni  this  morning  to  the  second  in  onr 
list  of  mahxrinl  fevers,  namely:  Simi)le  Ilemittent  Fever. 

Definition.— A  continued  fever  with  daily  exacerbations,  due 
to  the  presence  of  the  bacillus  malariie  in  the  blt.od.  It  is 
ushered  in  by  a  chill,  and  is  characterized  by  frontal  headache, 
epigastric  uneasiness,  functional  disturbance  of  tlie  liver  and 
occasionally  jaundice.  Toward  the  end  of  the  first  week  tlie 
da'ly  remissions  may  become  less  and  less  distinct,  and  typhoid 
symptoms  supervene.  The  average  duration  of  simple  remit- 
tent fever  is  two  weeks.  Mild  cases  may  terminate  within  six 
days.  Uncomplicated  cases  rarely  prove  fatal.  After  death, 
evidences  of  catarrhal  intlammation  of  the  intestinal  tract,  with 
bronzed  liver,  and  pigmentation  of  the  blood  and  tissues  are 
found. 

Synonyms.— Bilious  fever,  bilious  remittent  fever,  continued 
fever,  acclimative  fever. 

Historical  Notice.— Simple  remittent  fever  is  pre-eminently  a 
disease  of  warm  climates  and  malarial  districts.  In  this  coun- 
try it  is  most  prevalent  in  the  southern  and  western  states,  and 
may  be  endemic  during  the  summer  and  autumn  months.  It 
is  the  fever  of  Hungary,  Africa,  and  the  Pontine  marshes  of 
Italy.  Alexander  the  Great,  James  I.  and  Oliver  Cromwell  are 
said  to  have  died  of  it. 


Etiology  .- 

70 


-This  has  been  considered  already  in  our  lecture 


CLINU'Ar,   HISTOKY. 


77 


md  in  oar 

•er. 

tions,  tlup 
oil.  It  is 
lieiulache, 
liver  and 
week  the 
id  typhoid 
|)le  remit- 
kvithin  six 
tor  death, 
tract,  with 
issues  are 

continued 

■minentlya 
this  coun- 
states,  and 
lonths.  It 
narshes  of 
omwell  are 

our  lecture 


on  flimi)lo  intormittont  fever.  No  doubt  can  at  the  im'sentilayhe 
reasonably  eutertaiiieil  Imt  that  au  inteiiser  action  of  tlie  saino 
malarial  i)oison-the  baciUus  lualnria^  wJiioh  ^ivesriso  to  inter- 
uiittent  fever,  can  produce  remittent  fever.  Malarial  epideniics 
frequently  begin  as  intermittents,  change  to  remittents  at  their 
height,  and  return  to  intermitteiits  during  their  (h'cHno.  Asa 
rule,  the  two  forms  of  fever  do  not  prevail  in  tlio  same  K)cality 
at  the  same  time.  Sporadic  cases  due  to  peculiarities  of  con- 
stitution and  differences  in  susceptibility  to  the  poison  may 
however  occasionally  occur  within  the  same  area.  In  the  same 
latitude,  malarial  fever  may  be  remittent  along  the  sea  coast,  and 
at  the  same  time  intermittent  on  the  high  lands.  Simple  remit- 
tent fever  has  the  same  gcMtgraphical  limits,  and  is  governed  by 
the  same  laws  of  develo|)ment  and  distril)ution,  as  simple  in- 
termittent fever.  Its  b(mndaries,  from  (JS"  north  latitude  to  57" 
south  latitude,  encircle  the  earth  as  with  a  broad,  irregular  belt, 
running  in  the  main  parallel  with  the  equator.  At  the  northern 
and  southern  limits  of  this  nndarial  zone  the  types  of  fevers  are 
rare  as  to  frequency  and  mild  in  character,  but  become  extremely 
prevalent  and  severe  on  approaching  the  equator.  Other  things 
being  equal,  remittents  require  a  higher  average  range  of  tem- 
perature than  is  necessary  for  the  development  of  intermittents. 

Ciillieal  History. — The  premonitory  stage  of  this  disease  is 
usually  short,   but  its   attentling  phenomena  are  well  marked. 
The  initial  symptoms  are  those  of  general  malaise,  with  head- 
ache,  sleeplessness  and  oppression  in  the  epigastrium.     After 
twenty-four  or  forty-eight  hours  the   attack  commences,   not 
gradually  but  abruptly,  and  mostly  with  a  chill.     As  a  rule,  the 
chill  is  not  so  severe  nor  of  as  long  duration  as  that  of  intermit- 
tent fever.     It  appears  as  a  general  coldness  of  tlio   surface, 
rather  than  as  a  shaking  oi  the  body  Avith  chattering  of  the 
teeth.     During  the  chill,  as  in  the  cold"  stage  of  intermittents, 
the  thermometer  in  the  axilla  will  show  a  rise  of  two  or  three 
degrees  in  the  temperature  of  the  body.     Accompanying  the 
chill  there  is  intense  headache,  with  pain  in  the  back  and  limbs. 
Following  the  chill,  which  is  from  half  an  hour  to  an  hour  in 
duration,  the  febrile  condition  appears,  and  continues  unabated 
for  six,  twelve,  or  even  forty-eight  hours.    The  temperature  may 
at  this  period  of  the  attack  reach  105^  or  106°  Fahr.     The  skin 
becomes  hot,  dry  and  harsh.     The  pulse  increases  in  force  and 


^fi 


<Mmm» 


itimiimitm 


78 


LECTUllEH  ON   FEVKliH. 


fiwiuoncy,  but  Holdoni  rxnrcilrt  110  or  1 1.'»  honts  to  tln>  minute. 
Tim  fiico  Im'cuiiu'h  lluHlit'tl  aiid  tli<\  oyos  Hull'uscil.     Tlio  patient  Ih 
icHtloMH,  HloeplesH,  iiud  incapable  i)f  nu-nlal   exertion.     The  op- 
prehHioii  ami  tomlernerts  at  the  eijigaBtriuni  iucreatse,    and  Jiaiiseii 
and  vouiitiuy  boconie  more  peraintent.     The  vomiting  Ih  at  Hrnt 
oi"  the  eoutents  of  the  Btonuieli,  »ind  afterward  «»f  a  ntringy  mu- 
fUH,  tinged  with  green.     In  Hevero  cases,  blaek  vomit  may  oecur. 
The  tongno  beoomea  coated,  and  tliere  in  great  thirHt.     The  uri- 
nary Kccretion  becomes  scanty,  and  is  loaded  with  urea.     The 
bowels  are  usually  constipatetl  at  this  beginning  of  the   attack. 
AVhen   diarrhea  occurs,  the  stools  are  tinged  Avith  bile.     After 
continuing  with  increasing  severity  fnmi  ten  to  twelve   Lours, 
these  symptoms  begin  to  subside;  a  slight  i)erspiration  appears 
upon  the  forehead,  and  extends  in  a  short  time  t)ver  the  entire 
body;  the  pulse  falls  ten  or  twenty  beats  per  minute,  but  never 
reaches  the  normal.     The  thirst  diminishes  and  the  irritability 
t)f  the  stomach  lessens.     The  headache  almost  disappears  and 
the  i)atient  falls  into  a  quiet  and  refreshing  slumber.    The  tem- 
jjcrature  declines  as  the  symptoms    abate,  but  never  entirely 
reaches  the  natural  standard.     Usually  in  from  four  to  twenty, 
four  hours  the  febrile  movement  re-appears  with  increased  se- 
verity, preceded  or  not  by  a  slight  chill.     The  patient's  discom- 
fort again  increases,  and  the  restlessness  becomes  extreme.    The 
headache  returns,  and  delirium  may  at  times  ai)pear.     The  gas- 
tric symptoms  are  now  marked  and  severe.    The  tongue  is  thickly 
covered  with  a  yellowish  coating.     The  skin  becomes  hot,  diy 
and  jaundiced. 

All  the  symptoms  of  this,  the  second  exacerbation,  resemble 
those  of  the  first,  but  are  more  severe  and  of  longer  duration. 
The  partial  subsidence  of  the  fever  is  attended  by  a  less  profuse 
persi)iration  than  during  the  primary  paroxysm,  and  the  remis- 
sion is  not  so  well  marked. 

The  period  of  increase  of  fever  is  known  as  the  eoracrrbalion. 
The  time  that  elapses  between  the  subsidence  of  the  fever  and 
the  api)eDra]ice  of  the  exacerbation  is  called  the  remission. 

Exacerbations  and  remissions  are  characteristic  of  a  fully  de- 
reloped  case  of  simple  remittent  fever.  The  exacerbations  are 
ni)t  to  occur  about  midday,  and  the  remissions  at  midnight.  In 
protracted  cases  the  remissions  may  not  occur  until  morning. 
Oftentimes  the  paroxysm  follows  the  double  tertian  type,  and 


CLINICAL   IllWiOUV. 


79 


tliH  minuto. 
lu  patit'iit  itt 
u.  The  op- 
aud  iiims«»rt 
ig  in  at  Hrst 
Hlriiigy  luu- 

iiiay  (H'cur. 
t.     The  nri- 

wrea.  The 
tlio  attack, 
bile.  After 
clve  hours, 
ion  appears 
f  the  entire 
e,  but  never 

irritability 
appears  and 
\  The  tem- 
^ver  entirely 
ir  to  twenty- 
ncreased  se- 
nt' 8  discom- 
;treme.  The 
r.  The  gas- 
ue  is  thickly 
aes  hot,  dry 

m,  resemble 
er  duration, 
less  profuse 
id  the  remis- 

'xacprhaiion. 
he  fever  and 
misstoi}. 
if  a  fully  de- 
srbations  are 
lid  night.  In 
itil  morning, 
iiin  tyiip.  and 


tlit'H  ilicexHCi'rbation  ocrurHonoday  in  the  morning  and  the  next 
day  ill  the  ai'ternoctn.  In  sevoro  attai-kn.  the  pantxynni  may  be 
that  of  a  double  (|uotidiai».  One  jMiroxysni  will  then  appear  at 
noon  and  another  at  niidniglit;  the  remissions  taking  i)laco  in 
the  evening  and  morning. 

After  the  second  paroxysm  the  advance  is  various.  Tsunlly 
on  the  third  day  the  exacirbation  again  ajjpears,  sc^verer  in  form 
mid  of  longer  duration  than  tiie  preceding  (me.  The  remission 
succ'tu'ding  is  proportionately  more  incomplete.  From  day  to 
day  tiie  febrile  sympttmis  continue  to  recur  and  abate,  until 
the  niinissions  disappear  and  the  fever  assumes  the  continued 
tyi)e.  or  else  become  more  marked,  and  eventually  imss  into  in- 
tcn-missions.  In  fav»>rable  cases  the  disease  shows  signs  of  de- 
cline after  the  fifth  exacerbation.  If,  however,  the  disease  pro- 
gresses,  by  the  end  of  the  first  week  the  remissions  are  no  lon- 
ger discernible,  and  the  fever  becomes  a  continued  fever. 

Each  returning  exacerbation  from  this  time  on  tends  tmly  to 
lower  the  patient  into  that  typhoid  state  which  is  frequently 
mistaken  for  typhoid  fever,  but  which  is  liable  to  occur  in  all 
fevers.  The  skin  now  feels  extremely  dry  and  harsh ;  the  coun- 
tenance is  dark  or  flushed;  the  tongue  becomes  parched;  dark 
and  black  matter,  called  sordes,  collects  upon  the  teeth;  a  brown- 
ish diarrhea  at  times  takes  the  place  of  the  constipation.  In 
some  cases  there  is  local  tympanites.  Muscular  debility  is  usu- 
ally great.  The  pulse  numbers  120  or  140  beats  per  minute,  and 
is  small,  thready  and  feeble.  All  the  symptoms  deepen,  and 
ataxic  phenomena  aiipoar.  Deglutition  becomes  difficult.  The 
patient  is  unable  to  raise  himself,  and  is  continually  sliding 
down  in  bed;  his  hands  tremble,  and  there  is  subsultus  tendi- 
num  and  carphologia. 

This  order  of  things  may  continue  for  a  week  or  ten  days; 
when,  if  the  patient  is  to  enter  upon  convalescence,  remissions, 
frequently  attended  by  a  critical  discharge  from  the  kidneys, 
bowels  or  skin,  become  more  and  more  marked,  and  the  febrile 
exacerbations  gradually  disappear.  In  fatal  cases  the  remissions 
do  not  take  place,  but  the  typhoid  symptoms  deepen,  and  death 
ensues  either  from  exhaustion  or  as  a  consequence  of  complica- 
tions. Death  from  exhaustion  occurs  more  among  the  aged, 
and  in  intensely  malarial  regions.  Otherwise,  death  within  the 
first  three  weeks  is  almost  always  the  result  of  inflammatory 


80 


LECTUUES   ON    FEVEKS. 


complications.  Meningitis,  gastritis  and  pneumonia  are  among 
the  most  frequent  complications;  wliilo  chronic  hepatitis  and 
splenitis  apiiear  later,  and  may  be  considered  as  sequels  rather 
than  as  complications.  The  seqiiels  are  oftentimes  more  to  be 
dreaded  than  the  disease. 

When  simple  remittent  fever  is  accompanied  by  a  more  than 
usually  severe  gastro-hepatic  catarrh,  as  evidenced  by  excessive 
bilious  vomiting  and  jaundice,  it  has  been  termed  by  some  writ- 
ers, bilio'is  remittent  fever. 

ANALYSIS   OF   CHART. 

Chill.— The  onset  of  the  fever  is  generally  abrupt,  usually 
with  a  chill.  The  chill  is  less  complete  and  of  shorter  duration 
than  that  of  either  intermittent  fever  or  imeumonia.  A  general 
coldness  of  the  surface  is  present  at  the  beginning  of  the  chilly 
sensation.  The  shaking  of  the  body  and  chattering  of  the  teeth, 
common  in  intermittents,  are  not  experienced  in  remittents. 
There  is  rarely  a  marked  chill  after  the  first  paroxysm. 

Paroxysms. — The  paroxysms  during  the  first  week  are  made 
up  of  exacerbations  and  remissions.  When  the  fever  is  prolonged 
into  the  second  wee^r  the  remissions  disappear,  and  reappear 
only  as  convalescence  begins  to  be  established.  The  tempera- 
ture of  simple  remittent  fever  varies  from  100°  to  105°  Fahr. 
During  the  first  two  days  it  is  from  1°  to  2°  lower  during  the 
remission  than  during  the  exacerbation.  At  the  time  of  the  in- 
itial chill  it  is  from  2°  to  3°  above  the  normal.  After  the  third 
day,  unless  convalescence  sets  in,  there  is  but  little  fluctuation. 

The  Circulatory  and  Respiratory  Systems. — The  pulse 
increases  in  frequency  as  the  temperature  rises,  and  may  reach 
110  or  120  beats  per  minute,  in  the  primary  paroxysm.  During 
the  first  remission  it  may  fall  ten  or  twenty  beats  per  minute. 
After  the  third  paroxysm  it  becomes  more  frequent,  and  is 
apt  to  be  small,  thready  and  feeble.  The  respirations  are 
moderately  accelerated  fluring  the  exacerbations  of  the  first 
week,  and  may  range  from  20  to  25  ^-er  minute  in  uncomplicated 
3ases.  During  the  period  after  the  first  week  the  respirations 
may  be  either  hurried  and  shallow,  or  else  abnormally  slow. 

The  NerYOiis  System. — He;idache  is  one  of  the  earlier  and 
more  constant  symptoms.     It  is  usually  present  among  the  pro-  ■ 
dromes.     It  is  most  severe  during  the  first  week,  and  terminates . 


^-mi^^^s^- 


i 


a  are  among 
epatitis  and 
quels  rather 
J  more  to  be 

a  more  than 
by  excessive 
y  some  writ- 


apt,  usually 
ter  duration 
.  A  general 
of  the  chilly 
:  of  the  teeth, 
remittents, 
sm. 

sek  are  made 
■is  prolonged 
ad  reappear 
Ihe  temyera- 

0  105°  Fahr. 
f  during  the 
ae  of  the  in- 
ter the  third 
)  fluctuation. 

—The  pulse 
d  may  reach 
sm.     During 

per  minute, 
juent,  and  is 
pirations  are 

of  the  first 
Qcomplicated 

1  respirations 
,lly  slow. 

e  earlier  and 
long  the  pro- 
id  terminates 


CHART. 

CHART  111.— Simple  EcmiHcnt  Fever. 


81 


Preiuiinitdiy 
Symptoms: 

Maliiisr',            Nausea,            Cephalaltfia,            Coateil  Toiijrue. 

Initial  Pympttims 

Alinipt  chill.         A  jfcneraJ  coldness,  lasting  from  S  to  1  hour. 

Ocninil 
Symptoms: 

luirins  first  week. 

After  first  week. 

/ 

Form, 

Quotidian,  Uoublo  Tertian  or  Double 
Quotidian. 

Cont;nu(Kl  ft^ver. 

E.xaoerbations 

without  remissions. 

Sta»fe, 

E.xaeerbatlon, 

Kemisslon. 

Temperature: 

10;5"  to  106°, 

Paktial  Subsidence  op  aij.  Symptoms: 

Tiie  temperature  and  pulse  never  reach  the  natund 

Etandanl. 

103°  to  lOd". 

Pulse; 

Full, 
no  to  120 
per  minute. 

Small  and  feeble, 
120  to  NO 
per  minute. 

Kespiration: 

Hurried, 

Quick. 

Nervous  system: 

Throl)bin>r  headncho, 
Kestlessness, 
Sleeplessness, 

Active  delirium, 
Subsultus  tendinum, 
Carphologia. 

Stomach : 

Thirst,  nausea, 
Epitfastric  uneasi- 
ness.   Vomiting  of 
irreen.  strintry  mucus 

Vomiting 
less  constant. 

Face : 

Flushed, 

Flushed. 

Eyes: 

Suffused, 

Dull  and 
expressionless. 

Muscular  system: 

Violent  pain  in  back 
and  limbs. 

Great  muscular 
debility. 

Urine: 

Scanty, 

Loaded  with  urea. 

Skin: 

Dry— yellow, 

Slight  perspiration. 

Dry,   hot   and 
jawtidiiCd. 

Tonsfue: 

Yellow  coating. 

Dry  and  fissured. 
Sorties  on  teeth. 

Bowels : 

Constipated.    Diarrhoea  at  close  of  week. 

Brownish  diarrhopi. 

Complications: 

Meningitis,    Cerobritis,    Gastritis,    Entodtis  and  Pneumonia. 

Sequels: 

Chronic  hepatitis  and  splenitis. 

Duration : 

14  days.    May  terminate  before  the  fifth  day. 

Prognosis: 

Favorable. 

Etiology: 

The  Bacillus  Malaria?. 

II 

!;1 


m 


LECTURES   ON   FEVEllS. 


after  that  time  upon  the  advent  of  delirium.     AA  nkefuhiess  is 
ol'ton  a  prominent  and  annoying  symptom.  Subsultus  tendinum, 
carphology  or  grasping  in  the  air,  and  picking  at  the  bedclothes 
may  appear  during  the  typhoid  state  in  cases  prolonged  beyond 
the  first  week. 

The  Digestive  Traot.-The  affections  of  the  digestive  sys- 
tem ccmsist  mainly  of  perverted  functions,  and  of  catarrhal  con- 
ditions of  the  mucous  membrane  of  the  alimentary  tract.  Ihe 
tongue  is  at  first  coated  with  a  whitish  or  yellowish-white  fur. 
The  edges  present,  as  in  malarial  diseases  generally,  a  pectini- 
form  appearance;  the  margins  are  smooth,  and  both  preseiit  a 
clearer  appearance  and  a  brighter  hue  than  the  remainder  of  the 
surface  of  the  organ.  After  the  first  week,  in  severe  cases,  the 
tongue  becomes  parched,  and  at  times  cracked,  feordes  begin  to 
collect  upon  the  gums  and  teeth,  if  the  fever  runs  high  and  is 
prolonged  beyond  the  first  week.    , 

Thirst  is  a  prominent  symptom,  especially  during  the  exacer- 
bation.    Nausea  and  vomiting  are  invariably  present     The  mat- 
ters ejected  usually  consist  of  thin,  stringy  mucus,  tmged  with 
green!     In  severe  attacks  there  may  be  a  slight  amount  of  black 
vomit.     Epigastric  tenderness  is  generally  well  marked.    The 
liver  is  slightly  enlarged  in  most  cases.     Constipation  is  a  com 
n,on  symptom.      When  diarrhea  occurs,  it  is^  usually  mild,  and 
the  evacuations  are  brownish  in  character.     In  rare  ^-^^^^^l 
be  so  excessive  as  to  endanger  the  life  of  the  patient  f xom  p  o  - 
tration.     Tl.e  skin  is  generally  dry  and  more  or  less  jaundiced. 

Morbid  Anatomy.-The  pathological  ^\-^g^«,f  .  t^P^f^^e^^ 
™itte3.t  fever  resemble  very  much  those  of  ;^7l«  ^^^^^^^^ 
fever      And  as  both  types  of  fever  are  due  to  the  action  of  t  e 
same  n.alarial  poison  with  only  a  difference  m  ^^-^^^^y    ^he 
slme    l^aracteristic  changes  in  the  blood  are  -pe---^^-.^f ^ 
.-ith  a  difference  only  in  degree.     The  numl>er  of   red   Wood 
globules  is  dinunished  in  both,  as  is  also    he  amount  o^  fibnn 
and   albumen.     And  there   is   an   accumulation  of  ^J^-'^^^ 
amount  of  yellowish-red,  brown  or  l>lack  pigment  matter.     This 
"^Z^U^^  (Fig.  9)  is  r-sent  in  the  form  ^^^^^^ 
colls  containing  granules,  in  the  blood,  spleen    ^^J'    ^  ^]^  >.^; 
brnin,  spinal  cord,  etc.     These  granule,  are  o^^'^\^^''^\^l 
remittent  than  in  intermittent  fever.     Their  accumulation  m  the 


\, 


wi^ 


DIFFEItENTIAL   DIAGNOSIS. 


'illness  is 
andinum, 
tlclotlies, 
d  beyond 

jtive  sys- 
rrlial  con- 
act.  The 
vliite  fur. 
a  pectini- 
present  a 
der  of  the 
cases,  the 
?s  begin  to 
gh  and  is 

he  exacer- 
The  mat- 
nged  with 
nt  of  black 
:ked.     The 
I  is  a  com- 
mild,  and 
ases  it  may 
from  pros- 
jaundiced. 

simple  re- 
ntermittent 
tion  of  the 
aantity,  the 
need  in  both 

red  blood 
nt  of  fibrin 

a  variable 
atter.  This 
ranules  or  of 
er,  kidneys, 
r  present  in 
ilation  in  the 


general  circulation  can  easily  be  shown  in  a  drop  of  blood  drawn 
during  life,  after  a  series  of  paroxysms  have  occurred.  By  some 
writers  the  spleen  is  thought  to  be  the  point  of  origin  of  this 
pigment  matter;  and  by  others  the  pigmentation  is  believed  to 
be  due  to  the  hajmatine,  which  has  escaped  from  the  corpuscle  in 
consequence  of  changes  in  the  plasma  as  regards  the  amount  of 
albumen  and  sodium  chloride  it  contains.  The  latest  and  most 
probable  theory  is  tliat  the  granules  owe  their  origin  to  the 
changes  in  the  red  corpuscle,  caused  by  the  destructive  action  of 
the  Ijacillus  malarise. 

Tlie  spleen  is  somewhat  enlarged  in  simple  remittent  fever, 
but  not  to  the  same  extent  as  in  simple  intermittent  fever.  The 
tumor  seldom  extends  below  the  margin  of  the  ribs.  The 
changes  in  the  alimentary  tract  are  such  as  attend  gastro-intes- 
tinal  catarrh.  The  mucous  membrane  of  the  stomach  and  in- 
testines is  more  or  less  congested,  thickened  and  softened.  In 
the  intestinal  canal,  the  Peyerian  patches  are  usually  enlarged, 
and  at  times  ulcerative  changes  may  have  taken  place.  The 
mesenteric  glands  are  frequently  hyperajmic,  but  are  neither 
enlarged  nor  granular. 

The  Lirer.— The  characteristic  pathological  lesion  ol  remit- 
tent fever  is  the  bronzed  liver. 

This  discoloration  is  uniformly  present,  though  it  may  vary 
in  degree  in  different  types.  It  is  bronzed  without  and  olive- 
green  within,  and  is  due  to  the  pigmentation  of  the  liver  tissues. 
The  organ  is  seldom  much  increased  in  size. 

Differential  Diagnosis.— Simple  remittent  fever  is  readily 
distinguished  from  simple  intermittent  fever.  Each  paroxysm 
of  simple  intermittent  fever  begins  with  a  chill;  while  in  simple 
remittent  fever,  after  the  primary  par  jxysm,  there  is  rarely  a 
marked  chill.  In  intermittent  fever  here  is  a  time  when  the 
patient  is  free  from  fever— the  intermission;  while  in  remittent 
fever,  there  is  no  time,  not  even  during  the  remission,  when  the 
patient  is  entirely  free  from  fever. 

The  symptoms  in  remittent  fever  simply  grow  and  decline, 
they  do  not  as  in  intermittent  fever,  appear  and  disappear. 

Keraittents  often  pass  into  intermittents,  and  vice  versa. 
Simple  remittent  fever  ought  not  to  be  confounded  witli  typhoid 


»Wli 


g.  LECTURES  ON  FEVEUS. 

And  vet  after  the  patient  has  pasBed  the  first  vreek  and 
fever.     And  jet,  aiiei  mc  i  pnsilv  be  made, 

entered  the  t„>hoia  state  the  -*^-;  ^^^L-ds  in  ,u.nUed 
The  Budden  appearance  o«  '^'J""    .  ,  ,„„     .jhe  range 

contrast  t.,  the  --'«»- "W""1,;ltsCdfc^^      Durin, 
„t  temperature  during  the  to  t^veekB^e^^^^ 

the  first  week  the  rennss.ons  Me  ™'y^^\lj^'%^^        «„  ,j,„p. 

and  there  is  «-l"™«>'^""'X:"—  »"'!  »'™"  *"  """- 
toms  (nausea  and  vomitmg)  are  com  ^^^^  ^^^ 

t^nt,  but  quite  rare  in  t^f  °f/™  V^t^ever  patients,  but 
generally  l-^'f  ^ '^^^^rLt  Ctis,  bronchitis,  and 
Z  rLtcCd  T^Srllmon  Uphoid  .,er,  .re  se.donr 
seL  in  the  typhoid  state  otrem*n|™^ 

The  "pea-soap"   discharges  °*    >;™ „(  ;,„ittent  fever. 

*ff-»t  '--  »\;,rZlr  Crdole-.  and  tympa- 
The  livid  countenance,  eleepin^  bt  f    . 

nites  are  almost  peculiar  to  tn;^«;y^^^^^^^    ^^^^-^  ,f  ter  remit- 

The  post-mortem  changes  are  g'^^*"«  7^;^^^^^  ^ ^^^,,    Remit- 

tent  Jer,.  an^  ^tenc  ^^:^S:^^Z^.  typhoid 

Remittent  fever  differs  from  ^JPl-^  ^^^^^^^^  typhoid 

appearance  ^Vr  rar '  T;;^:^^^^^^^^^^^^^     ^^^  ^^^^"^  ^ 
C^l^^drirstl^than  i^^^^^^^  ,„, 

The  differential  diagnosis  between  simple  re^^^^^ 

yellow  fever  is  sometimes  -  t«-f,f  ^^^^^  TremTttent  fever  pa- 
Piprment  granules  are  found  m  the  blood  ot  rem 
tients,  bui  not  in  that  of  yellow  iever  v-^-  ;.ous  urine,  though 
Hemorrhage  from  the  stomach,  -"^.^"'^^^J^^^^^^  in  yel  - 

seldom  found  in  remittent  '^-^'^^^^\^'^Z^^^         while  that 
low  fever.     The  headache  o  yeUow  fever  is  o     p^^^  ^^^^^  ^^^_ 

of  remittent  fever  is  frontal,     ^n^  ^""^"^^^^^         fever  rather 
tects  from  n  second,  while  one  attack  of  remitte 

predisposes  to  ^««tl^«^,^**'';; .  ,  ^  ^i^ee  on  the  third  day.    The 
In  yellow  fever  death  may  take^^^^^^^^^^^  fatally  before  the 

severest  cases  of  'f^'^^'^'^^'lJ^^     always  a  country  fe.er, 
^^:CK-The  prognosis  in  simple  remittent  fever  is  gen- 


jij^ifftaisss^.' 


TREATMENT   OF  HEMITTENT   FEVElt. 


85 


veek  and 
atle. 

n.  marked 
'he  range 
During 
ent  fever, 
•ic  symp- 
1  in  remit- 
nules  are 
ients,  but 
hitis,   and 
vre  seldom 

•e  entirely 
tent  fever, 
nd  tympa- 


if ter  remit- 

3r.    Eemit- 

lile  typlioid 

own. 

in  the  early 

ted  typlioid 

as  usually  a 

mt  fever  and 
ale  difficulty. 
)nt  fever  pa- 

jrine,  though 
ptoms  in  yel  - 
bal,  while  that 
ow  fever  pro- 
fever  rather 

ird  day.    The 
ally  before  the 
country  fefer, 
(ort  towns, 
it  fever  is  gen- 


erally f,'()od.  In  our  latitude  fatal  cases  should  rarely  occur. 
As  a  rule,  the  prognosis  is  less  favorable  in  tropical  than  in  t( m- 
jjerate  climates.  In  the  southern  states  where  the  severe  forms 
are  encountered,  a  fatal  termination  is  of  freque  nt  occurrence. 

The  favorable  indications  are:  The  early  subsidence  of  the 
gastric  symptoms;  a  lowering  of  the  temperature  range  and  a 
decrease  in  the  frequency  of  the  i)ulse;  a  turbid  appearance  of 
the  urine  and  the  formation  of  vesicles  about  the  lips.  Decided 
and  })rolongod  remissions  accompanied  by  copious  perspiration 
are  always  signs  of  approaching  convalescence. 

On  the  other  hand,  .iiort  and  incomplete  remissions  with  a 
t(nidency  to  collapse  t  the  close  of  the  exacerbations  are  un- 
f av(n'able  signs.  Othf  r  suspicious  synii)toms  are  increased  fre- 
quency and  extreme  weakness  of  the  pulse;  dryness  and  black- 
ness of  the  tongue;  hiccough;  intense  icterus,  and  retention  or 
supjn-ession  of  urine.  The  advent  of  cerebral  symptoms  or  of 
pneumonic  or  gastric  complications  are  additional  alarming 
danger  signals. 

An  attack  of  simple  remittent  fever  predisposes  to  subsequent 
attacks  of  simple  intermittent  fever,  wliile  such  sequels  of  the 
latter  disease  as  enlargement  of  the  spleen>  anaemia  and  general 
dropsy,  occasionally  follow. 

Duration. — The  average  duration  of  simple  remittent  fever 
is  fourteen  days.  Favorable  cases  often  terminate  in  an  inter- 
mission on  the  fifth  day.  Severe  or  ill-managed  cases  may  be 
protracted  for  t'lree,  five  or  even  six  weeks. 

Treatment. — The  prophylactic  treatment  is  the  same  as  for 
intermittent  fever. 

Gclsemiutn,  hnjonia,  eupatorium  a,nd  quinine  aie  the  principal 
remedies  during  the  attack. 

Oelseniiuni  is  especially  useful  during  the  first  week,  and 
will  often  terminate  the  fever  before  the  fifth  day;  it  is  adapted 
to  cases  coming  on  in  the  autumn,  and  recurring  in  spring;  in 
infantile  remittents  it  is  a  valuable  remedy;  the  exacerbations 
are  apt  to  occur  at  midnight,  while  the  remissions  appear  in  the 
morning,  and  are  frequently  accompanied  by  perspiration ;  there 
is  early  and  almost  complete  loss  of  muscular  power;  the  pulse 
is  large,  full  and  quick,  but  not  very  hard;  the  face  frequently 
has  a  crimson  flush;   there  is  intense  frontal  or  occipital  head- 


86 


LECTUllES  ON    FEVEllS. 


nche;  tho  head  teela  as  big  as  a  bushel;  tho  tonguo  has  a  pale 
red  color  or  else  is  covered  with  a  yellowish  white  coat,  and  there 
is  a  Kliiiiy,  bitter  tnste  in  the  mouth. 

Bryonia,  like  gelseraium,  is  particularly  indicated  during  the 
first  week  oi  the  fever.     It  is  adapted  to  pale  complexioned,  irri- 
table people.     The  exacerbations  come  on  in  the  afternoon,  i.nd 
the  remissions  are  not  well  marked.     The  headache  is  a  painful 
pressure  or  tearing  pain,  relieved  by  lying  down.     Delirium, 
when  it  occurs,  is  usually  about  business  affairs.    The  tongue  is 
thinly  lined  with  mucus;  the  lips  are  parched,  dry  and  cracked; 
the  taste  is  flat  and  pasty;  the  vomiting  is  bilious  m  character, 
and  occurs  especially  after  drinking;  the  bowels  are  constipated, 
or  else  the  discharges  are  diarrheic  mixed  with  mucus,  and  ot  a 
deep  brown  color;  the  urine  is  either  watery  and  clear  or  else 
yellow  with  a  yellow  sediment.     At  times  there  is  a  marked  dis- 
position to  perspire. 

Eiipatorium  perf.  is  adapted  to  summer  and  autumn  remit- 
tents that  are  attended  by  severe  bilious  symptoms;  there  is  in- 
tense occipital  headache;  the  tongue  is  coated  with  a  thick,  yel- 
low fur;  vomiting  occurs  after  drinking;  there  is  fullness  anu 
tenderness  in  the  hepatic  region,  with  stitches  and  soreness  on 
moving;  the  urine  is  scanty  and  dark  colored.  Aching  in  the 
bones  w^th  soreness  of  the  flesh  stands  out  as  a  prominent  char- 
acteristic in  remittent  as  well  as  intermittent  fever. 

Ipecac  may  be  needed  when  the  gustric  irritability  is  strongly 
marked;  there  is  frontal  headache,  with  disgust  for  food,  espe- 
cially greasy  food;  nausea,  with  regurgitation  of  the  ingesta; 
pale,  yellow  color  of  the  skin. 

Podophyllum  renders  excellent  service  when  there  is  much 
intestinal  'irritation,  and  the  febrile  symptoms  are  strongly 
marked-  the  gastro-intestinal  and  hepatic  symptoms  predomi- 
nate- there  is  violent  headache  with  excessive  thirst;  at  times 
the  headache  alternates  with  diarrhea!;  the  evacuations  are  bil- 
ious in  character,  and  there  is  a  sense  of  fullness  in  the  hepatic 
region,  with  twisting  pains;  sallowness  of  the  skin  is  a  common 
attendant.  • 

Quinine  will  be  of  service  at  the  commencement  or  at  the 
close,  when  the  remissions  are  well  marked,  and  the  fever  as- 


TltEATMENT   OF   1;KM1TTENT   FKVMt. 


S7 


has  a  pale 
t,  and  there 

during  the 
:ioned,  iiri- 
irnoon,  uud 
is  a  piinful 
Delirium, 
le  tongue  is 
nd  cracked; 
I  character, 
constipated, 
!us,  and  of  a 
lear,  or  else 
marked  dis- 

;umn  remit- 
there  is  in- 
a  thick,  yel- 
"uUness  and 
.  soreness  on 
;hing  in  the 
minent  char- 

;y  is  strongly 
r  food,  espe- 
the  ingesta; 

ere  is  much 
are  strongly 
ras  predomi- 
irst;  at  times 
tions  are  bil- 
nthe  hepatic 
is  a  common 

lent  or  at  the 
the  fever  as- 


sumes a  more  or  loss  distinctly  intcrmittt-nt  type;  it  should  he 
ndminisU'r(Hl  only  during  the  rciuissiun;  the  pulse  is  fioipioutly 
lluctuating  in  diaracter;  it  may  bo  woak  and  thready  during  tho 
remission,  but  full  and  compressible  during  the  exacerbation; 
humming  in  the  t^ars,  -vvith  a  sense  of  lightness  across  tlie  ver-. 
tex,  or  with  a  sense}  of  rumbling  thn)ugh  the  occiput  is  a  utrong 
indication  for  this  remedy. 

Mercurl'lis  may  prove  useful  in  weak,  delicate  individuals, 
during  the  first  week,  Avhon  there  is  intense  fever  in  the  evening, 
most  violent  at  midnight;  the  eyes  and  skin  are  yellow;  tho  liead- 
ache  is  worse  on  lying  down;  tho  taste,  eructations  and  vomiting 
are  all  bitter;  there  is  great  desire  for  sour  or  piquant  things; 
the  tcmgue  is  lined  with  whitish  mucus  or  a  dirty  yellow  fur; 
the  evacuations  from  the  bowels  consist  of  large  quantities  of 
bile  and  mucus;  the  stomach  and  liver  are  sensitive  to  pressure; 
tho  urine  is  of  a  dark  red  color,  as  if  mixed  with  blood. 

Nlix  vomica  in  irritable  sanguine  temperaments;  it  is  mainly 
useful  in  the  early  stages;  the  patient  is  exceedingly  irritable 
and  wishes  to  be  alone;  the  com[>lexion  is  bright  red  'vith  a  yel- 
lowish tinge;  the  tongue  is  dry  or  coated,  with  bright  red  edges; 
adapted  to  men  more  than  to  women. 

Baptisia.— After  the  first  week,  for  the  early  stages  of  the 
typlioid  state;  there  is  great  nervous  restlessness;  the  jmtient 
thinks  the  head  is  scattered  over  the  bed;  must  toss  about  to  get 
the  pieces  together;  sensation  as  though  there  were  a  second  self 
beside  the  patient  in  the  bed;  the  headache  is  dull  and  stupefy- 
ing; the  patient  falls  to  sleep  in  the  midst  of  an  answer;  the 
stuijor  resembles  that  of  arnica  and  opium;  the  jmlse  is  full  and 
slow;  the  tongue  is  dry,  with  a  brown  streak  down  the  center; 
the  breath  is  foetid;  sordes  collect  on  the  teeth;  there  is sinkin" 
fit  the  stomach,  and  the  patient  can  swallow  only  liquids;  the 
urina  is  high-colored,  and  the  evacuations  from  the  bowels  are 
dark  and  offensive. 

Opium  is  indicated  after  the  first  week  for  the  comatose  state; 
the  stupor  is  complete;  the  resinratioiiB  are  stertorous;  the 
stools  are  involuntary,  and  the  face  is  dark,  red  and  bloated. 

RhllM  tox.  for  conui,  less  jironounced  than  tliat  of  oi)ium;  the 
mental  operations  of  the  patient  are  slow  and  difficult;  there  is 


88 


LECTUllKH  ON   I'KVEllS. 


roHtlosH  Hleep  with  frightful  droaiuB;  tlu.  pationt  tr^ks  im.a>ov. 
ontly;  the  tongun  in  rod  at  tho  lii>  an  tin,  shape  of  a  tnan^lu, 
tho  lii)H  aro  dry  and  covered  witii  br.nvii  crunts. 

Hv«sevaniUH  for  coutiim.mB  delirium,  illusions  and  Imlluc.na- 
ti  "s;  tl^  patient  jumps  .mt  of  bed  and  '^tt-p  s  t>  n.n  ...  ^^ 
he  has  no  Avants  except  thirst;  there  is  muttenn,',  ^^  1  ^"^ 
at  tho  bedclothes,  and  at  tin.es  subsultus  f  >'^">"--'  "^.  !.^^"*^ 
is  red  or  brown,  dry  and  cracked;  the  stools  are  mvoluntaij. 

Belladonna  for  violent  .lelirium  with  attempt  t<>  ^^^J^;^ 
strike  bite  or  spit  at  attendants;  there  is  a  disposition  to  tea, 
tHiI;;  to  piecel,  the  symptoms  point  to  brain  congestion;  the 
tongue  is  red  at  the  margin  and  white  m  the  centre. 

Arsenicnu  alb.  may  be  needed  for  "f -^..-^.^^lit^afvi" 
cases prolonged  beyond  the  first  week;  weak,  debilitated  mdiMd 
uals  often  require  arsenic  during  convalescence. 

Pulsatilla  in  fevers  that  run  a  shnv  course;  it  is  ^"^Jable  to 
.vomen  and  children  more  than  to  men;  the  exacerbations  take 
pZ  hi  the  evening;  there  is  extreme  aversion  to  -umal  foxl 
Te  taste  is  bitter.^and  there  is  vomiting  of  --^^^^^^ 
there  is  a  whitish  mucous  coating  on  the  tongue;    he  stomach 
S^^i^are  sensitive  to  pressure;  tj-e  is  ingh%  ^.m^-; 
and  the  stools  are  watery  or  green  like  bde;  Pulsatilla  >  ^ll  ""^" 
relieve  the  excessive  hunger  that  appears  ^^"7f  fj^^^^^^^^^ 

Crotalus  and  Phosphorus  have  been  suggested  for  the  intense 
icterus  of  remittents  in  southern  latitudes. 

For  further  therapeutic  indications  I  will  ''-f «^^ f"^  J;;. *^^^ 
treatment  of  simple  intermittent  fever,  as  given  in  the  previous 

lecture. 


tU( 

!... 

of 

wa 

thf 

wh 

of 

La] 

,ks  iiu'ohor- 
a  trianyUi; 

(1  hallvioiim- 
()  run  iiway; 
ni\\  picking 
;  the  tongue 
oluiitnry. 

run  nwny,  to 
ition  t(i  tpftv 
igestiou;  the 

ontlitiouH  in 
:ated  incUvicl- 

H  suitable  to 
I'bationH  take 
animal  food; 
icus  and  bile; 
;  the  stomach 
itly  diarrhrea, 
tilia  will  often 
convalescence, 
"or  the  intense 

er  you  to  the 
n  the  previous 


LECTURE  VI. 

Periiicious  Fever. 

The  third  and  last  of  the  fevers  caused  solely  by  tlie  presence 
in  the  human  organism  of  tlie  liigldy  active  malarial  poison- 
tlie  bacdius  malariio  -is  Pernicious  Malarial  Fever. 

Definition.— It  is  a  malignant  and  destructive  malarial  fever 
cliaracterized  by  special  dangerous  local  aftections  in  important 
organs      It  may  take  the  form  of  either  an  intermittent  or  a  re- 
mittent.    Ihe  pernicious  attacks  are  of  tlie  tertian  or  quoti.lian 
type,  and  may  occur  at  any  time  of  tlie  day  or  night     The  per 
incious  symptoms    usually  appear  with  the    second   or  tliird 
paroxysm.     Pernicious  fever  is  not  infrequently  epidemic,  and 
may  assume  one  of  the  following  varieties:  the  cornafo,r  the 
<idmous,  the  choleraw,  the  algul,  the  colliquaiivc  or  the  icfrHc 
It  tends  to  terminate  fatally  unless  controlled  before  the  third 
paroxysm. 

8ynonynis.-It  has  been  called  Congestive  fever,  Malignant 
Intermittent,  Malignant  Eemittent,  Ardent  fever.  Jungle  fever 
and  Tropical  typhoid  fever. 

History.-Pernicious  fever  is  a  rare  disease  in  northern  lati- 
tudes,  but  18  quite  common  in  the  vicinity  of  the  rice  plantations 
of  the  southern  states.  It  tends  to  prevail  at  certain  epochs  in 
warm  and  intensely  malarial  districts.  Dr.  Daniel  Drake  states 
that  of  the  interior  valley  of  North  America,  the  regions  in 
which  It  has  most  frequently  prevailed  are,  "the  level  portions 
of  Alabama,  Mississippi  and  Louisiana,  the  southern  shore  of 
Lake  Michigan  from  Chicago  around  to  St.  Joseph  river  and 


90 


LECTUKEri  ON   lUVEUH. 


f  LakoSt    Clair  an<l  Lak.  Erio,  from  Lako  Huron   I..  Lako 
OnS.  uL  tho  ctuarie.  of  tl.  c,r.,ks  and  r.v.r. 
Ktlolo«y.--TUe  exciting  and  p..aU.K.i>^c^s^o^ 

fever  are   similar  to.  but  m.>ro  ^^'^iJ^^^^^V^^.^o  (;.5 
nialarial  fevrn.     A  ^^^^' '"'^^^^y^Zvln^' ^ 
Fahr  )  than  in  necessary  to  i.roduce  eittioi  Hunpi.)  i 
Splo  remittent,  i.  required  for  its  acvelopment. 

Varieties  -The   foll<.wing   well-marked   and  distinct  fornm 

Cl.„i»».  Hi,t„ry.-Pe™iciou,  fever  ^ayj^gin*^^^^^^^^ 

ge..™Hy  jtB  1-''--^ ;;„;^4r  E  ««  vSe,  the  „tt„ck 
malarial  fevers.     In  the   majoruy  paroxysm 

eommonces  with  a  ^^Z\ClZlT!^^a^^^^^^^  or  a 

remittent  fever,     une  ^^^^^^^  the  pernicious 

f'^tr^nrfever^^^^^^^  *n-  may  be  quotidian 

character  of  <^'^^  ^^^^  p^^  •  ^^^^  symptoms  usually  manifest 
tertian  or  quartan.  ^^^^^'f  "J"'  ^d  mroxysm.  In  the  quo- 
themselves  during  the  --"^  ^  ^^^^  Ehe  second  or  third 

L  \  milff  rm  of  malarial  fever  may  pass  into  a  permciouB 
r  K  „  moSrsive  aggravation  of  symptoms;  or  a  single 
fever,  by  a  f  "f^^^^^^^J^eritv  may  suddenly  be  followed  by 
paroxysm  of  not  unusual  ««^^"^^  -^  .  ^  ^j  J  ^^^^^d  or  third 
aperniciouB  one  ^^^^^^^^^^^  toes  and  fingers. 

repetition.     A  «^™^^^^^  ^^i^iie  the  trunk  and  head  are 

coiitmuing  hrou^^^^^^^^^^^  ,f  ,,Hg 

"^^'Z       At  tiTefa  distinct  init^^^ 
rytrdrn^Wy^cognizable  as  one  o^J^^e  Weties  of 
pLnicious  fever.     One  of  the  most  common  forms  is  the 

rnmatose  Vai'ietv.-The  only  suggestive  symptom  of  its  ap- 
petra^ceTs  tll^^^^^^^^      of  more  headache,  vertigo,  apathy  and 


n'iiii'iriii'iiiiii»iiiTii»"i»' 


.M&iifi. 


DELir.IOUS   VAUIETY. 


1)1 


u  to  Liiko 

povnicious 
I  the  otht^r 
riituro  ( i)') 
atoriiiitteut 

tinct  forms 
laracterizcil 
.cterized  by 
vcteri/.oil  by 
l(ji(l  ntridn, 
OU8  Hurface; 
ig;   ami  tlio 

bruptly,  but 
of  the  other 

15  the  attack 
lie  paroxysm 
rmittent  or  a 
:if  the  inter- 

16  pernicious 
36  quotiilian, 
illy  manifest 

In  the  quo- 
iconcl  or  third 
il  the  second 
o  a  pernicious 
;  or  a  single 
e  followed  by 
jcond  or  third 
!S  and  fingers, 
:  and  head  are 
Lgn  of  malig- 
ay  be  followed 
e  "varieties  of 
3  is  the 

)tom  of  its  ap- 
To,  apathy  and 


diaturbnnfo  of  speech  during  either  an  intermittent  or  n  rcniit- 
tciit  piiroxysni,  than  ordinarily  occurs  in  a  siniph^  form  of  mala- 
rial i't'ver.  After  the  chilly  stag*',  and  during  either  llif  Jiot 
stage  of  an  intormittent  or  the  »'xucerbation  of  a  remittent,  iho 
patient  jjasses  into  a  state  of  stupor  and  unconscitmsncHH.  He 
lies  upon  his  back.  The  eyes  are  dosed  and  the  pupils  dilated. 
The  face  is  hot  anil  tlnshed.  The  skin  is  hot,  dry,  and  jaundiced. 
The  respirations  are  stertorous.  The  pulse  may  be  eitlier  slow 
t)r  freipient.  The  temperature  reaches  105'  Fahr.  or  107^  Fahr. 
If  the  case  is  to  terminate  fatally  in  this  paroxysm  tlie  synip- 
toms  of  coma  continue  deepei,  unc(m8ci((usness  becomes  com- 
plete, the  heart  power  weakens,  the  pulse  becomes  iirej^iilar,  and 
the  ijatient  dies.  Usually,  however,  after  the  comatose  symp- 
toms have  continued  for  ten  or  twelvi*  lumrs  the  patient  it'tunis 
to  consciimsness  in  the  midst  of  a  jjrofuso  sweat.  Thehead.iche 
and  vertigo  now  disappear,  and  according  to  the  tyj)e  there  nmy 
be  a  well-marked  remission  or  a  distinct  intermission.  At  this 
stage  the  case  may  recover.  But  frequently  with  (lie  next  re- 
mittent exacerbation  or  the  hot  stage  of  an  intermittent,  all  the 
symptoms  return  with  increased  severity,  the  citupor  b'  imes 
more  marked,  and  the  patient  jjasses  into  fatal  coma.  Even 
when  the  patient  lingers  beyond  the  second  ])aroxyBm,  be  is  apt 
to  succumb,  apparently  from  cerebral  compression. 

Delirious  Variety. — The  delirious  variety  is  of  less  fre- 
quent occurrence  than  the  one  we  have  just  described.  As  the 
patient  passes  into  the  exacerbation  of  a  remittent  or  the  hot 
stage  of  an  intermittent,  active  delirium  appears.  This  delirium 
difi'ers  from  the  ordinary  delirium  of  malarial  fevers  in  that  it  is 
violent  in  character,  and  is  preceded  by  intense  headache,  ring- 
ing in  the  ears,  and  great  restlessness.  The  face  is  either  flushed 
or  pale  and  sunken.  The  eyes  are  glistening  and  the  conjunctivio 
injected.  The  pulse  is  full  and  hard,  and  the  carotids  beat  vio- 
lently. The  skin  is  hot  and  dry.  The  temperature  rarely  falls 
below  105°  Fahr.  and  often  reaches  107"  Fahr.  or  108°  Fahr.  This 
condition  may  last  for  hours.  Somewhat  suddenly  the  patient 
sinks  into  collapse,  or  passes  gradually  into  deep  coma  from 
which  he  never  awakens.  In  favorable  cases  the  delirium  be- 
comes less  and  less  marked,  profuse  perspiration  appears,  and 
the  patient  falls  into  a  prolonged  sleep,  from  which  ho  awakes 
to  consciousness  with  headache  and  vertigo,  Init  without  the 


wamaammmm 


wmmwmmimimtimii;  ..- 


i. 

I 


jin*HVjlL.,_^ 


M 


LECTLIIES  ON   FKVEliS. 


Hliylitt'Ht  rpcollootiitn  of  what,  haw  tak(>u  phieo.  A  third  or  fourth 
rep»;til,ioii  of  thoj,  roxyHiu  is  apt  to  provo  fatal.  AttimoHfpilop- 
tifi'viii  <ioiivii]sioiis  or  totniiii!  HpaHitiH  HCfoinpauy  or  tako  tho 
plat'i)  of  tliu  ildiriiiMi. 

(iiolernic  Vurh't.v.  Jn  tho  ri^oh'raic  variety,  wliiciv  is  of 
frpqnt'iit  orcurrcm-i',  tiu'  [)atit'n*^>  aifor  i)asainj;  into  tlui  })■>■  Htagc 
i(f  an  intfrniitti'nt.  or  tho  oxa^-prliatiou  of  a  reniittont,  i-.,iul- 
(It'iily  H'-i/'.'.d  witli  t'liohu'.' ii!  nyniptoiUH.  Tlic  vomiting  in  Hovon^ 
anil  yoUowi.-'.  in  character,  anil  tho  ovacuationH  from  tho  bowols 
ar»>  oithor  Avi'it\''y  anil  grofuiirth,  or  rcHomlilo  blooiy  wutor.  Tlio 
thirst  is  apt  to  ui  iiitoin^e.  Thoro  in  a  houbo  of  M-oight  and  hnrn- 
ing  in  tho  ojjigaHtriuni  u.cdnipaniod  with  oranips  in  thu  calvoa 
of  tho  logH,  coltlnt'i^s  of  tho  nkin  andoxtrome  ri'stloKHnoHB.  The 
pulHo  is  almost  imporceptiblo,  and  tho  rcspirationH  consist  of  a 
dotiltlo  inspiration  followod  liy  n  donblo  sighing  oxpiratiiri.  Oc- 
casionally there  is  great  dyspnoia,  caused  by  ovorwholiru  vp-  con- 
gestion of  tho  lungs.  As  death  approai-hes  tho  pulso  br/;omes 
hurried,  irregular  and  tliiHoring.  Tl  .  r^ypimtions  become  nioro 
and  nioro  prolonged  anil  sighing,  and  tl-n  skin  becomes  bathed 
in  a  cold,  clammy  i)orspii'ation.  The  du)utiru  of  a  fatal  i)arox- 
ysni  is  from  three  to  six  hours. 

Algid  Variety. — The  algid  variety  is  ns  n  rule  confined  to 
warm  climates.  It  rosomlilos  somewhat  tho  choleraic  variety, 
and  its  progress  is  very  insidious.  It  is  characterized  by  mni- 
l)le-like  coldness  of  tlie  body.  As  the  patient  enters  the  exac- 
erbation of  n  remittent  or  the  hot  stage  of  an  intermittent,  and 
notwithstanding  he  comi)Iain8  of  burning  heat  and  intense  thirst, 
the  surface  of  the  body  grows  cold.  The  skin  becomes  pale  and 
livid,  and  is  covered  with  a  cold  sweat.  The  temperature  in  the 
axilla  may  be  two  or  three  degrees  below  tlie  natural  standard. 
The  pulse  is  irregular,  small  and  thready,  and  the  respiration  is 
superficial  and  slow;  the  breath  is  cold,  and  tho  voice  is  hoarse 
and  feeble.  The  tongue  is  pale  and  cold,  and  the  epigastric  re- 
gion is  sensitive  to  pressure;  muco-bilious  vomiting  is  a  not 
uncommon  symptom.  The  urine  is  scanty,  dark-colored  and  of 
high  specific  gravity.  The  patient  is  conscious  but  apathetic,  and 
wears  the  countenance  of  death.  Usually  the  paroxysm  marches 
steadily  on,  till  death  closes  the  scene.  If  recovery  is  to  take 
place,  the  pulse  returns  in  the  wrist,  the  warmth  comes  to  the 


MSf-iifiritfiiwiMmiiKijilMgaiiftiUpi 


iH%_ij]^i|H 


I  or  fourth 

leHf'pilop- 

•    tllko    till! 


liiciv  IH  of 
)  lioi  rttngc 
nt,  irt  „ucl. 
i  in  Hovcro 
tlio  buwols 
itor.  Tlio 
iiiul  burn- 
tliu  ciilvos 
iCHH.  TJie 
)iisiHt  of  a 
liion.  Oc- 
lirrlvip-  con- 
1  br/jomes 
?onie  nioro 
lOB  bathed 
itiil  parox- 

onfinecl  to 
lie  variety, 
jil  by  mia- 
3  the  exac- 
itteiit,  and 
iuse  thirst, 
!s  pale  and 
tiiro  in  the 
standard, 
piration  is 
9  is  hoarse 
gastric  re- 
g  is  a  not 
red  and  of 
thetic,  and 
m  marches 
'  is  to  take 
mes  to  the 


r 

J 


■^?'7' 


^  <f 


[-^ 


«•  i 


CIHM/ICMH 

Microfiche 

Series. 


CIHIVI/ICIVIH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


!Sia»iWfllW«»1««SS<ltW£A«iWiir4';i<i^^ 


COLLIQUATIVE  VARIETY. 


93 


surface,  and  the  patient  enters  upon  a  slow  convalescence.  Not 
unfrequently  a  typhoid  condition  like  that  ah.  -  cholera,  super- 
venes. 

Colliquative  Variety.— In  the  colliquative  variety  a  continu- 
ous sweat  sets  in  at  the  close  of  the  hot  stage,  accompanied  by 
great  prostration  and  coldness  of  the  surface.  This  variety 
tends  to  end  fatally  after  the  second  or  third  paroxysm.  In 
such  cases  the  pallor  of  the  skin  and  mucous  membrane  becomes 
strongly  marked;  the  heart's  action  grows  more  and  more  feeble; 
the  respiration  becomes  labored,  and  the  patient  sweats  to  death. 

Icteric  Variety.— The  icteric  variety  is  generally  endemic,, 
and  is  oftener  engrafted  on  an  intermittent.  It  begins  with  a 
long-continued  chill,  attended  with  jaundice.  The  jaundice  rap- 
idly deepens  and  the  whole  body  assumes  a  saffron  hue.  Early 
in  the  attack  there  is  intense  nausea,  with  bilious  vomiting  and 
diarrhea;  there  is  intense  headache,  and  a  feeling  of  numbness 
in  the  limbs;  the  tongue  is  coated  white  or  yellow,  and  the  thirst 
is  excessive;  there  is  pain  in  the  region  of  the  liver  and  spleen; 
the  pulse  is  small,  frequent  and  hard;  the  urine  is  scanty  and 
presents  a  deep  red  color.  At  the  appearance  of  the  hot 
stage  all  the  symptoms  grow  more  intense;  the  pulse  becomes, 
more  frequent;  the  respirations  become  labored;  the  skin  is 
hot,  and  the  thirst  intense;  the  temperature  reaches  106°  Fahr., 
or  107°Fahr.;  the  vomiting  and  diarrhea  continue,  and  the 
urine  becomes  more  and  more  scanty,  and  tenesmus  appears. 
This  stage  lasts  from  three  to  five  hours,  and  may  terminate 
in  death.  If  a  fatal  termination  does  not  take  place  at  this 
point,  the  patient  passes  into  the  sweating  stage.  The  skin 
is  now  bathed  in  a  profuse  sweat,  and  under  proper  treatment 
the  patient  enters  upon  convalescence.  In  relapses,  death  gen- 
erally follows  in  the  second  or  third  paroxysm. 

ANALYSIS  OP  CHART. 

The  Nerrons  System. — More  or  less  complete  coma  charac- 
terizes the  comatose  variety.  It  sets  in  at  the  onset  of  the  hot 
stage  and  may  continue  for  a  considerable  time.  Severe  head- 
ache and  vertigo  are  early  symptoms  of  the  delirious  and  icteric 
varieties.  The  delirium  in  the  delirious  variety  varies  from 
that  of  the  lightest  grade  to  the  most  violent  maniacal  spells. 
Eclampsia  occurs  mostly  among  children  and  puerperal  women.. 


■RM 


II  ■_  1 II  >  I  (1 . -M  -1,1-  .1.-  J..  1  'j^umjWiiiiiM 


94 


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LECTURES  ON  FEVE118, 


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Hydrophobic  symptoms  too,  sometimes  occur  in  tho  delirious 
variety  m  women.  Convulsions  frequently  complicate  the  chol- 
eraic  variety.  In  convalescence  from  the  latter  variety  there  is 
frequently  wakefulness,  with  irritability  of  temper  and  partial 
loss  of  memory.  The  headache  in  the  icteric  variety  is  intense 
and  increases  as  the  attack  progresses.  In  unfavorable  icteric 
cases  the  patient  passes  into  a  state  of  coma  and  dies. 

The  Cutaneous  Surface.-The  skin  is  hot  and  dry,  and  the 
face  flushed,  in  the  comatose  and  delirious  varieties;  it  is  hot 
dry,  and  intensely  jaundiced  in  the  icteric;  and  it  is  generally 
pale  cold  and  clammy  in  the  choleraic;  in  the  algid  it  is  pale  and 
livid,  and  has  a  marble-like  coldness;  in  the  colliquative  it  is 
covered  with  a  profuse  and  frequently  cold  sweat. 

The  Alimentary  Tract.— The  tongue  is  dry  and  often  cov- 
ered  with  a  fuliginous  coat  in  the  comatose  variety.  Thirst  is 
great  in  all  varieties.  In  the  choleraic  variety  the  symptoms  re- 
semble those  of  cholera;  vomiting  is  yellowish  in  character  in 
the  choleraic  fonn,  and  is  attended  with  burning  thirst.  In  the 
algid  variety  the  vomiting  is  muco-bilious  in  appearance,  and 
in  the  icteric,  decidedly  bilious.  In  the  choleraic  and  icteric 
varieties  the  intestinal  symptoms  are  of  decided  importance, 
but  in  the  algid  they  are  only  subordinate.  Serious  hemor- 
rhages  from  the  stomach  and  bowels  sometimes  occur,  and  are 
apt  to  endanger  the  life  of  the  patient.  Dysenteric  symptoms 
at  times  appear  suddenly  during  a  febrile  attack,  associated 
•with  cerebral  manifestations. 

The  Circulatory  and  Respiratory  Systems.— In  the  coma- 
tose variety  the  pulse  is  sometimes  fast  and  sometimes  slow; 
and  the  respirations  are  rapid  and  stertorous.  In  the  delirious 
variety  the  pulse  is  full  and  hard;  when  tetanic  spasms  occur  it 
is  irregular.  In  the  choleraic  form  the  pulse  is  small  and  hardly 
perceptible  early  in  the  attack,  and  irregular  and  thready  towards 
tha  close.  The  respirations  are  shallow  and  as  slow  as  ten  per 
minute.  As  death  approaches  the  pulse  and  respiration  come  to 
a  complete  stand-still. 

The  Temperature.— In  the  comatose,  delirious  and  icteric 
forms  the  thermometer  usually  shows  a  temperature  of  from 
105°  Fahr.  to  108°  Fahr.  In  the  algid  variety  the  temperature 
is  oftener  below  than  above  the  natural  standard;  while  in  the 


96 


LECTURES  ON  FEVERS. 


k 


choleraic  and  colliquative  varieties  it  remains  at  a  variable  point 
above  the  normal  until  near  the  close  of  life. 

Morbid  Anatomy. — The  anatomical  lesions  of  pernicious  fever 
differ  in  degree,  but  are  similar  in  kind  to  those  which  take  place 
in  intermittents  and  remittents.  Free  pigment  and  bacilli  (Fig. 
9)  are  found  in  the  blood  in  larger  quantities  than  in  any  of  the 
other  malarial  fevera  The  white  corpuscles  are  diminished  to 
one-half  or  one-third  their  normal  number.  And  secondary  con- 
gestion of  the  abdominal  viscera  is  a  decidedly  prominent  autop- 
sic  phenomenon. 

Differential  Diagnosis.— In  the  diagnosis  of  pernicious  fevef' 
the  character  of  the  prevailing  fever  is  of  great  importance.  For 
when  the  pernicious  form  is  prevailing  in  a  locality  the  diagno- 
sis can  easily  be  made;  while  in  other  cases,  differentiation  will 
be  easy  or  difiBcult  according  to  the  type  of  fever.  From  simple 
intermittent  or  simple  remittent,  it  can  readily  be  distinguished 
after  the  first  paroxysm,  by  the  intensity  of  tixe  symptoms  and 
the  general  prostration. 

From  apoplexy  it  can  be  diagnosed  by  remembering  that  hemi- 
plegia, which  is  a  constant  and  prominent  symptom  of  the 
former,  is  of  rare  occurrence  in  tbe  latter.  The  coma  and  hemi- 
plegia of  pernicious  fever,  when  present,  are  usually  preceded 
by  intense  febrile  excitement,  while  in  apoplexy  their  onset  is 
sudden  and  without  fever. 

From  meningitis  it  may  be  diagnosed  by  the  history  of  the 
case,  and  the  sudden  appearance  of  the  coma.  In  meningitis, 
several  days  elapse  before  the  delirium  passes  into  coma.  In 
pernicious  fever  one  or  two  malarial  paroxysms  usually  precede 
the  attack  of  coma  or  delirium.  In  meningitis  the  pupil  is  di- 
lated during  the  coma,  while  in  the  comatose  variety  of  perni- 
cious fever,  it  may  be  contracted,  dilated,  or  normal. 

From  cholera  the  choleraic  and  algid  forms  may  be  distin- 
guished by  the  early  history  of  the  endemic,  the  elevated  tem- 
perature, and  the  character  of  the  primary  discharges.  The 
choleraic  discharges  of  pernicious  fever  are  not  profuse,  and  are 
characteristically  preceded  by  one  or  t^'o  bloody  discharges. 
The  urine  of  cholera  contains  albumen,  while  that  of  pernicious 
fever  does  not;  and  finally,  the  blood  of  pernicious  fever  will  be 
found  to  contain  pigment,  while  that  of  cholera  will  not 


\ 


■Itita 


PnOQNOSIS. 


97 


He  point 

ious  fever 
bake  place 
cilli  (Fig. 
any  of  the 
inished  to 
idary  con- 
ent  autop- 

jious  f  evei* 
tance.  For 
he  diagno- 
liation  will 
■om  simple 
itinguished 
ptoms  and 

;  that  hemi- 
om  of  the 
1  and  hemi- 
[y  preceded 
eir  onset  is 

tory  of  the 
meningitis, 
)  coma.  In 
ally  precede 
pupil  is  di- 
jty  of  perni- 

y  be  distin- 
ilevated  tem- 
larges.  The 
fuse,  and  are 
r  discharges, 
jf  pernicious 
fever  will  be 
ilnoi 


From  yellow  fever  the  icteric  variety  mny  be  distinguished  by 
the  history  of  its  development,  and  by  the  fact  that  when  endemic 
it  rarely  troubles  new-comers,  but  attacks  those  who  have  been 
for  some  time  resident  in  the  neighborhood.  Yellow  fever  at- 
tacks by  preference  those  who  have  recently  moved  into  the  in- 
fected district.  The  jaundice  of  pernicious  fever  appears  earlier 
in  the  disease  than  that  of  yellow  fever.  Bloody  urine,  which  is 
pathognomonic  of  the  icteric  variety  of  pernicious  fever,  rarely 
occurs  in  yellow  fever. 

Prognosis. — The  prognosis  is,  as  a  rule,  unfavorable,  for  un- 
less  the  disease  is  controlled  before  the  second  or  third  attack, 
the  case  is  apt  to  terminate  fatally.  Under  appropriate  treat- 
ment, however,  statistics  show  that  not  more  than  from  twelve  to 
fifteen  per  cent.  die.  In  all  cases  much  will  depend  upon  the 
character  and  stage  of  the  epidemic.  The  ratio  of  mortality  is 
invariably  greater  at  the  beginning  than  at  the  close  of  the  epi- 
demic. The  prognosis  is  ahvays  unfavorable  when  the  paroxysms 
increase  in  severity  and  duration;  the  patient  is  apt  to  die  in  the 
third  or  fourth  paroxysm.  Distinctintermissions,  however  short, 
render  the  prognosis  less  grave.  The  tertian  type  of  fever  is 
the  most  favorable.  Severe  dysentery  coming  on  at  the  end  of  a 
paroxysm  is  an  unfavorable  sign;  and  generally  when  the  second 
or  third  paroxysm  is  protracted,  and  has  such  ominous  accom- 
paniments as  extreme  restlessness  and  anxiety;  epistaxis;  de- 
lirium or  coma;  intense  epigastric  pain;  numbness;  red,  scanty 
urine;  vomiting  and  diarrhea;  exhausting  sweats,  or  feeble  and 
almost  imperceptible  pulse;  the  prognosis  is  very  unfavorable, 
and  the  patient  may  die,  not  later  than  the  fourth  or  fifth  parox- 
ysm. Occasionally,  as  a  paroxysm  subsides,  a  continued  fever 
with  tjrphoid  symptoms  appears,  and  runs  its  course  in  ten  or 
twelve  days,  terminating  fatally. 

The  most  fatal  cases  of  pernicious  fever  are  the  choleraic  and 
the  algid.  The  most  likely  to  recover  are  the  coniatose,  the  de- 
lirious and  the  icteric.  The  death-rate  is  greatest  among  the  in- 
temperate, and  at  the  extremes  of  life. 

Treatment. — The  treatment  of  pernicious  fever  must  of  ne- 
cessity be  prompt,  vigorous,  and  well-timed,  for  often  the  issue 
of  life  or  death  hangs  on  a  single  hour.  Frequently,  early  in 
the  disease  the  usual  avenues  for  the  introduction  of  remedies 


98 


LECTURES  ON  FEVERS. 


into  the  system  are  closed,  as  the  patient  as  either  anable  to 
swallow  or  the  stomach  rejects  everything  as  soon  as  taken.  In 
'Ich  cases  the  hypodermatic  administration  of  our  remedies 
becomes  an  imperative  necessity.  And  in  general,  the  immedi. 
ate  therapeutical  effect  of  administering  ^'^'^^^f  ^««  "l  ^^J^^ 
ner  is  greater  than  by  the  usual  i>c'r  os  method  of  admmis- 

tration. 

Hypodermatic   Medication.-Five  drops  of  the  desired  at- 
tenuation  of  the  indicated  remedy  mixed  with  five  drops  of 
wlr.  may  be  introduced  beneath  the  skin  into  the  subcutaneous 
rilular  tissue,  with  the  hypodermatic  syringe.    The  silver  or 
German  silver  syringe  is  the  best,  and  preference  shoula  be 
^ven  to  a  needle  Ld!  of  gold  with  a  hardened  or  indium  pmnt^ 
The  syringe  may  be  charged  with  the  required  dose  of  solution 
by  drLing  the  fluid  up  into  the  barrel  by  aspiration.     Should 
afr  enter  4ile  the  fluid  is  being  drawn  up,  nivert  the  syringe 
andpush  up  the  piston  slowly  until  all  air  is  expelled    Fromfive 
"twenty  minims  of  solution  is  the  ^ "^it^  ^^^^  f  ^t 
teredat  e'ach  hypodermatic  injection.  The  «?«* --^^^^y/J^^^ 
ed  for  the  injection  is  the  arm  about  the  -^-tion  of  tf  ^"^^'^ 
Care  must  always  be  taken  to  avoid  puncturing  a  ^em.     Where 
a  patient  is  very  timid  or  intolerant  of  pain,  the  sensibility  of 
:he1;^n  may  be'lowered  by  applying  a  piece  of  cotton  or  cloth 

moistened  with  chloroform  to  the  «f  ^^^t'  fl'Sti^^^^^^^^^ 
main  a  few  minutes.  Preparatory  to  making  the  injection  take 
UP  a  loose  fold  of  skin  between  the  thumb  and  index  finger  of 
rie?t  hand ;  then  push  the  needle  in  with  a  ^l-k  -^^^^^^^^^^^^ 
motion,  at  a  right  angle  to  the  f o  d.  As  Boon  as  the  needle 
penetrates  the  skin  all  resistance  to  its  further  Vrogc^^ce..es^ 
Pass  the  needle  along  in  the  subcutaneous  tf  ^^.^f/^  *^^^^^^^^^^ 
for  from  three-fourths  of  an  inch  to  one  inch.  Make  the  mjec- 
tlT'  the  contained  liquid  slowly  and  6-"^ -^^^^-^  *^^ 
needle  slowly,  using  pressure  with  the  finger  at  point  of  punct- 

uro  to  prevent  any  escape  of  the  solution.  ^    •   •    l^a 

TreLioussolutionsofquininewhensubcutaneouslyinjec^^^ 

frequently  excite  considerable  burning    and  a  zone  o^^^-^ 
less  redness  for  some  distance  around  the  puncture.    This  im 
tation  can  be  readily  allayed  by  applying  a  wet  compress  to  the 

^^Tib^'methJdormedication  inaugurated  by  Wood,  of  Edin- 


TREATMENT. 


99 


anable  to 
aken.     In 

remedies 
Q  immedi- 

this  iiian- 
'  admiuis- 

iesired  at- 
)  drops  of 
jcutaneous 
)  silver  or 

should  be 
iium  point, 
of  solution 
n.  Should 
;he  syringe 

From  five 
ly  adminis- 
lonly  select- 
the  deltoid, 
in.    Where 
msibility  of 
an  or  cloth 
ing  it  to  re- 
jection take 
lex  finger  of 
and  decided 
i  the  needle 
;res8  ceases, 
der  the  skin 
ce  the  injec- 
ithdraw  the 
nt  of  punct- 

usly  injected 
}  of  more  or 
).  This  irri- 
apress  to  the 

od,  of  Edin- 


burgh, and  introduced  into  this  country  by  Dr.  Fordyce  Barker, 
of  New  York,  in  1856,  is,  I  am  positive,  destined  to  inaugurate  a 
new  era  in  the  method  of  administration  of  homoeopathic  rem- 
edies in  sudden  and  dangerous  tjrpes  of  disease,  and  perhaps 
also  in  chronic  ailments. 

Principal  Remedies.— Gelsemium,  etc.— Early  in  pemiciouB 
malarial  fever,  and  before  the  pernicious  character  of  the  attack 
has  been  definitely  stamped,  gelsemium,  or— according  to  the 
indications — one  of  the  remedies  mentioned  in  a  former  lecture 
on  the  treatment  of  simple  intermittent  fever,  will  be  indicated. 

Qninite  bl-suiphas.— As  soon,  however,  as  the  pernicious 
character  of  the  paroxysm  becomes  apparent,  and  without  regard 
to  the  stage  of  the  paroxysm,  administer  either  the  acid  or  the 
neutral  sulphate  of  quinine  (which  is  soluble  in  water)  hypoder- 
matically,  in  from  one  to  two-grain  doses  every  hour,  until  the 
time  for  the  next  paroxysm  is  passed.  By  so  doing  you  will  be 
very  apt  to  prevent  a  return  of  the  febrile  movelnent,  and  thus 
save  the  life  of  your  patient  Quinine,  as  a  rule,  in  such  cases, 
Acts  simply  to  prevent  a  recurrence  of  the  much^ireaded  parox- 
ysm, and  hence  whatever  organic  changes  are  produced  by  a 
long-continued  action  of  the  malarial  poison,  must  be  correct- 
ed by  appropriate  treatment  subsequently,  before  the  patient 
can  be  pronounced  cured. 

As  intercurrent  and  exceptionally  as  substitutive  remedies, 
the  following  may  be  epitomized  for  further  study: 

1.  Comatose  Fane/^.— Opium  or  rhus  tox. 

2.  Delirious  Fane/i/.— Hyoscyamus  or  belladonna. 

3.  Choleraic  Variety.— kn.  alb.,  verat  alb,,  podophyllum. 

4  Algid  Fane/i/.— Camphor,  carbo  veg.,  menyanthes,  verat 

alb. 

5.  Colliquative    Fane/t/.— Cinchona,  jaborandi,  phosphorus. 

6.  Icteric  Farie^t/. -Crotalus,  eupat  perf.,  bryonia. 

The  prophylactic  and  hygienic  treatment  is  the  same  as  for 
simple  intermittent  fever.  Externally,  direct  heat  may  be  ap- 
plied with  hot-water  bottles  or  hot  sand  bags  laid  along  the 
spine.  Stimulating  enemas,  and  friction  to  the  surface  may  also 
act  as  aids.  In  collapse  a  tablespoonful  of  brandy  or  whisky  may 
be  given  every  half  hour  or  hour,  until  reaction  occurs.  As  re- 
gards the  use  of  stimulants  at  other  times,  the  condition  of  the 
patient  must  be  your  guide. 


ffl 


r 


LECTUKE  VII. 

Chronic  Malarial  Infection. 

R«fore  leaving  the  diseases  caused  by  that  malarial  poison, 
,^tZllZl^^,  I  must  say  something  about  Chbokic  Ma- 

LABIAL  IKFECTION  or  MaLABIAL  CACHEXIA. 

l)efliiitioii.-Chronic  malarial  infeotion.  though  a  frequent 
sequel  of  acute  malarial  disease,  may  exist  as  ^P^^^^f  ^^^^J 
Stenselv  malarial  regions,  without  any  antecedent  attacks  of 
^Irir/eC    Toilluskate    one  individual  may  after  frequent 
rettTtionsof,  or  incomplete  recovery  from  intermittent  or  re- 
mSent  fever  become  anemic,  show  on  physical  examinat  on 
Tnltgeme^^^^      the  liver  and  spleen,  and  otherwise  present  the 
peculfrphenomenaof  chronic  malarial  infection;  ^^/^^^^^^ 
Edud.  after  Uving  for  some  time  under  -a^anal  influ  n^e 
ly  present  the  same  phenomena  of  chronic  «^-  ^^  "^f  ^^^ 
theaS»mia.andthe  enlarged  liver  and  spl^f  ^' *^°;8^  ^^  "^^^ 
never  have  had  a  distinct  paroxysm  of  malarial  fever. 

Synonym.— Malarial  Cachexia. 

Ftioloev  -Its  etiology  is  the  same  as  of  malarial  fevers  in 

1.1     It  mav  result  from  either  a  long-continued  exposure 

fnTsUght  y  mS  district,  or  a  short  exposure  in  a  strongly 

Xi'l  region.     The  excessive  use  of  quinine  predisposes  to 

malarial  cachexia.  . 

Clinical  Hi8tory.-Patients  suffering  from  -'^^^]^^^^^ 

infection  generally  complain  -fj^'^ig-'^^^^/S^ltt^S 
and  disturbances  of  vision.    They  perspire  c^P^P^^.  ^*  ^^^^^^ 
^d  on  the  slightest  exertion.     Pain  and  oppression  at  the  epi- 
100 


MOBBID  ANATOMY. 


101 


•ial  poison, 
IBONIO  Ma- 

a  frequent 
iry  affection 
t  attacks  of 
ker  frequent 
ittent  or  re- 
examination 
present  the 
'hile  another 
ial  influence 
Lai  infection, 
lugh  he  may 
3r. 


rial  fevers  in 
aed  exposure 
in  a  strongly 
redisposes  to 

•onic  malarial 
ig  in  the  ears, 
ausly  at  night 
Ion  at  the  epi- 


gnstrium  is  a  frequent  symptom.  The  tongue  is  covered  with  a 
ye  Ho  wish- white  cont;  the  mouth  is  dry  and  the  taste  metallic. 
There  are  nausea,  anorexia,  and  frequently  morning  diarrhea. 
The  sleep  is  usually  disturbed;  or  if  profound  is  uurcfreshing. 
Many  complain  of  wandering,  dragging  or  burning  pains  in 
the  back,  along  the  sciatic  nerve,  and  over  the  coccyx.  The 
latter  region  is  frequently  painful  on  pressure.  Others  hove 
stiiTuess  of  the  muscles  of  the  limbs  and  back,  and  suffer  from 
fatigue  and  palpitation  of  the  heart,  on  the  slightest  exertion. 
Anojsthesia  of  the  outer  surfaces  of  the  thighs,  numbness  of  the 
iirms,  and  burning  of  the  feet  are  quite  common  symptoms. 
While  hemiplegia  and  neuralgia — especially  of  the  fifth  ner\'e — 
are  among  the  occasional  nervous  manifestations.  Patients  suf- 
fering from  long-continued  malarial  poisoning  are  very  apt  to 
become  the  victims  of  melancholia  and  hypochondi'iasis.  The 
skin  presents  a  yellowish  pale  hue.  The  urine  is  generally  about 
normal,  though  at  times  it  is  profuse,  and  of  low  specific  gravity. 
In  severe  attacks  it  may  be  scanty  and  dark  colored.  The  tem- 
perature and  pulse  are  usually  normal,  though  the  latter  may  be 
variable.  The  liver  and  spleen  are  enlarged,  hard,  and  sensitive 
to  pressure.  In  prolonged  and  severe  cases,  oscites  is  developed, 
hemorrhage  from  the  nose  occurs,  and  furuncles  oppear  on  the 
cutaneous  surface. 

Morbid  Anatomy. — The  anatomical  changes  which  take  place 
in  malarial  cachexia  resemble  those  of  the  severer  types  of  ma- 
larial fever.  The  spleen  is  oftentimes  enormously  enlarged,  and 
presents  the  changes  of  either  simple  hyperplasia  or  amyloid 
degeneration.  Its  surface  is  uneven,  the  capsule  much  thickened, 
and  its  substance  proper  is  very  rich  in  pigment  matter.  Simi- 
lar changes  take  place  in  the  liver;  and  the  kidneys  are  some- 
times extremely  hypersemic.  Amyloid  and  fatty  degeneration 
occasionally  appears  in  the  muscular  tissue  of  the  heart  The 
skin  is  always  anaemic,  and  frequently  there  is  oedema  of  the 
subcuttmeous  cellular  tissue.  An  accumvdation  of  fluid  in  the 
serous  cavities  often  co-exists.  Pigment  granules  and  vacuolated 
red  corpuscles  are  found  in  great  numbers  in  the  blood.  In 
profound  ansemia  the  number  of  red  corpuscles  may  fall  from 
five  millions  to  less  than  one  and  one  half  millions  per  cubic 
millimeter  of  blood. 


102 


LECTUIIE8  ON  FEVEHS. 


Diirerential  DiagnoslH.— The  mnin  oharnctcristics  of  clironio 
mnlarial  infection  nre:  enlargement  of  the  liver  nnd  spleen;  a 
])ur()\y8inul  (lispuuition  in  all  the  lunnifestntiouH;  the  preuonce 
<)f  frt'o  pigment  in  the  blood  in  severe  cnses;  vertigo  with  ring- 
ing in  the  ears;  n  disposition  to  cutarrlml  inflammation  of  the 
gastro-intestiual  and  respiratory  tracts;  a  tendency  to  melancholy 
and  hypochondriasis;  attacks  of  neuralgia;  anoomia,  with  piUpi- 
tation  of  the  heart;  anasarca  and  general  dropsy. 

And  the  occurrence  of  such  a  chain  of  symptoms  in  an  indi- 
vidual who  has  repeatedly  suffered  from  malarial  fever  parox- 
ysms, or  has  resided  in  a  malarial  district  even  though  he  may 
not  have  had  a  distinct  malarial  paroxysm,  or  who  has  been 
drugged  or  overdosed  with  quinine,  is  sufficiently  suggestive 
of  malarial  cachexia. 

Prognosis. — As  regards  the  prognoBis  we  may  say  that  the 
milder  grades  usually  recover  under  appropriate  treatment* 
nrhile  in  the  severe  forms  death  may  result  from  exhaustion 
with  dropsical  symptoms,  Bright's  disease,  lung  affections,  or 
from  apoplexy  due  to  pigment  embolism.  And  generally,  the 
greater  the  area  of  splenic  and  hepatic  dullness  the  more  xm- 
favorable  the  prognosis. 

Treatment. — The  patient  must  be  immediately  removed  from 
the  malarious  district  to  an  elevated,  warm  and  mountainous  re- 
gion. He  must  avoid  getting  wet,  and  must  also  observe  all  the 
hygienic  regulations  mentioned  in  the  lecture  on  intermittent 
fever.  The  diet  must  be  most  nutritious,  and  should  include  a 
moderate  allowance  of  light  wines.  Shower  baths,  and  frequent 
cool  baths  with  douches  to  the  region  of  the  liver  and  spleen, 
are  very  effective  measures. 

Principal  Remedies.— Arsenicum  Alb.  is  the  main  remedy 
for  chronic  malarial  infection,  especially  when  quinine  has  been 
used  to  excess.  It  is  particularly  indicated  when  there  is  a  ten- 
dency either  to  Bright' s  disease  or  phthisis.  The  guiding  symp- 
toms are:  anaemia,  with  great  debility,  and  oppression  of  breath- 
ing. Occasional  symptoms  are:  spasms  in  the  chest,  violent 
pains  in  the  stomach,  and  a  left  sided  neuralgia  associated  with 
hemiplegia,  also  left  sided.  A  decidedly  dropsical  tendency  is 
always  a  strong  indication  for  arsenic. 


DENOUE. 


103 


of  chronic 
l1  spleen;  a 
B  prewonco 
with  ring- 
ition  ot  the 
melftncholy 
with  palpi- 

in  an  indi- 
Eever  parox- 
ugh  he  may 
lo  has  been 
r  suggestive 

•  say  that  the 
;e  treatment, 
a  exhaustion 
affections,  or 
generally,  the 
the  more  vm- 


removed  from 
:)untainou8  re- 
)bserve  all  the 
a  intermittent 
ould  include  a 
and  frequent 
rer  and  spleen, 

)  main  remedy 
inine  has  been 
,  there  is  a  ten- 
guiding  symp- 
jsion  of  breath- 
_,  chest,  violent 
associated  with 
ical  tendency  i» 


Ferruill.— Is  adapted  to  chhoh  where  the  nniciniii  is  gront  and 
tho  debility  extreme,  i)rovided  ci>dunui  Imn  not  yet  appeiirtnl. 
The  stomacli  rojocts  all  food,  and  there  is  palpitation  of  tlie 
heart.  The  brcatliiug  is  dillicult,  and  tla-ru  is  oppression  of  the 
chest  as  if  some  one  pressed  with  tho  hand  upon  it.  Particu- 
larly useful  in  weak,  nervous  individuals,  antl  in  delicate  chlo- 
rotio  women. 

Nutriim  Mlir. — Is  useful  when  the  digestive  organs  are  af- 
fected, and  there  is  deticieut  nutrition.  There  is  great  emacia- 
tion and  great  prostration.  The  pulse  is  intermittent.  Tho  skin 
is  dry  and  sallow;  Tho  urino  is  light  and  watery.  And  the 
patient  is  depressed,  sad  and  melancholic. 

Lycopodiiini. — Is  indicated  when  the  digestive  disturbances 
are  due  to  hepatic  influences,  and  when  there  is  chronic  gastro- 
intestinal catarrh.  The  foce  has  a  yellowish  gray  appearance. 
The  hepatic  region  is  sensitive  to  pressure.  The  smallest  quantity 
of  food  produces  satiety.  Excessive  fullness  and  distension  of 
the  abdomen  from  flatulence  co-exists. 

Calcarea  Carb. — Is  useful  in  scrofulous  individuals  when 
there  is  a  tendency  to  glandular  swellings.  The  spleen  is  en- 
larged. The  patient  is  unable  to  walk,  perspires  and  has  palpi- 
tation of  the  heart  on  the  slightest  exertion.  The  stools  are 
white  and  undigested.  At  times  there  is  alternate  constipation 
and  diarrhea. 

Finally,  sulphur,  carbo  veg.,  mere,  bi-jod.,  phos.,  or  some  in- 
tercurrent remedy,  will  be  needed  to  meet  the  various  complica- 
tions that  may  occasionally  arise. 

Dengue. 

I  now  come  to  the  consideration  of  a  fever,  which,  though  not 
strictly  malarial  in  character,  has  a  right  to  be  classed  among 
miasmatic  or  infectious  fevers.  It  is  Denquk  Feveb  (pronounced 
daiKjay. ) 

Definition. — Dengue  is  an  acute  febrile  affection  of  short  du- 
ration which  appears  as  an  epidemic  in  hot  climates.  It  is  due 
to  an  unknown  external  specific  cause,  and  is  characterized  by 
two  distinct  and  essentially  different  febrile  paroxysms  separated 
by  a  remission.  It  is  accompanied  by  more  or  less  intense  ar- 
thritic pains,  and  occasionally  by  a  cutaneous  efflorescence  re- 


5fSJS!B«SBiW»S»!W-««W«»CET- 


104 


LECTUREB  ON  FEVERS. 


sembling  that  of  scarlet  fever.  Dengue  attacks  all  ages,  and 
botii  sexes,  and  is  an  extremely  painful  disease.  It  may  relapse, 
but  seldom  proves  fatal. 

Synonyms.— Break-bone  fever,  dandy  fever,  three-day  fever, 
stiff-necked  fever,  date  fever,  polka  fever. 

History. — The  earliest  account  of  dengue  fever,  according  to 
de  Wilde  dates  from  the  year  1779.  David  Brylon,  of  Java,  at 
that  time  described  under  the  name  knockcl  kooris  (bone  fever) 
an  epidemic  disease  which  prevailed  in  Batavia,  The  following 
year  Dr.  Rush  described  an  epidemic  which  occurred  in  Phila- 
delphia. In  1818  the  disease  appeared  at  Lima,  and  in  1826  at 
Savannah.  A  general  epidemic  started  at  St.  Thomas  in  the 
West  Indies,  in  1827,  and  spread  to  this  country  in  1828,  where 
it  appeared  at  Pensacola,  New  Orleans,  New  York,  Philadelphia 
and  in  some  other  cities.  An  epidemic  prevailed  in  Brazil,  in 
1846.  In  1848,  the  fever  again  appeared,  along  with  yellow 
fever,  in  New  Orleans,  Vicksburg  and  Mobile.  Two  years  later 
a  general  epidemic  starting  in  Charleston,  traversed  the  entire 
Southern  States.  In  1852,  it  appeared  in  Peru  and  was  followed 
by  yellow  fever.  For  four  consecutive  years  following  1864  it 
prevailed  in  Spain.  It  visited  Arabia  in  1871,  and  starting  at 
Bombay  and  Cananore  the  next  year,  it  spread  through  all  India. 
In  1880  a  mild  epidemic  prevailed  at  Charleston  and  in  several 
of  the  Gulf  cities. 

Etiology. — Dengue  is  a  disease  of  warm  climates,  and 
promptly  disappears  upon  the  advent  of  frost  It  prevails 
chiefly  in  cities,  and  travels  mainly  in  the  direction  of  the  lines 
of  human  intercourse.  The  nature  of  the  exciting  cause  of  this 
disease  is  at  present  unknown.  The  morbific  agent  is,  however, 
generally  believed  to  be  specific  in  character;  and  the  infection 
is  capable  of  being  conveyed  in  clothing  and  merchandise  from 
one  part  of  the  country  to  another.  The  period  of  incubation  of 
the  germ  is  from  three  to  five  days.  Dengue  is  usually  regarded 
as  non-contagious. 

Clinical  History. — The  initiatory  symptoms  usually  appear 
suddenly.     Sometimes  there  is  a  prodromal  stage  of  from  one  to 
three  days'  duration,  characterized  by  slight  chills,  headache,  a 
furred  tongue,  loss  of  appetite,  and  pains  in  the  back  and  along, 
the  spine.    In  the  majority  of  cases  the  patient  is  seized  with 


I  iiniinuwui !■  »Miiwriinini 


4 


DUUATION. 


105 


all  ages,  and 
I  may  relapse, 

ee-day  fever, 

according  to 
a,  of  Java,  at 
(bone  fever) 
uhe  following 
red  in  Finla- 
nd in  1826  at 
lomas  in  the 
1 1828,  where 
Philadelphia 
I  in  Brazil,  in 

with  yellow 
vo  years  later 
led  the  entire 

was  followed 
owing  1864  it 
id  starting  at 
>ugh  all  India, 
md  in  several 

climates,  and 
It  prevails 
m  of  the  lines 
;  cause  of  this 
it  is,  however, 
I  the  infection 
chandise  from 
:  incubation  of 
lally  regarded 

isually  appear 
of  from  one  to 
Is,  headache,  a 
»ack  and  along, 
is  seized  with 


intense  frontal  headache,  photophobia,  backache,  and  severe  pain 
in  the  joints.  Occasionally  the  first  symptom  is  an  acute  pain 
in  one  of  the  small  joints.  The  joints  now  swell  rapidly  and  a 
painful  stif&tess  of  the  muscles  appears.  The  skin  of  the  face 
and  neck  becomes  flushed  and  turgid.  The  temperature  may 
reach  107°  Fahr.  The  pulse  is  full,  hard  and  strong,  occa- 
sionally intermittent,  and  ranging  from  120  to  140  beats  per  min- 
ute. The  stomach  is  extrem;:ly  irritable,  and  there  is  burning 
pain  in  the  epigastrium  with  nausea,  and  bilious  vomiting.  The 
lymphatic  glands,  beginning  with  the  inguinal,  frequently  be- 
come enlarged  and  tender,  and  the  epididymis  is  much  swollen. 
A  primary  exanthem  resembling  the  efflorescence  of  scarlet  fever, 
but  of  a  duller  hue,  and  lasting  only  during  the  continuance  of 
the  fever  now  shows  itself.  This  constitutes  the  stage  of  in- 
vasioii. 

In  from  twelve  hours  to  two,  three  or  five  days,  the  fever 
suddenly  abates — ^frequently  with  the  occurrence  of  critical 
symptoms  such  as  profuse  sweats,  greenish,  foul-smelling  diar- 
rhea or  epistaxis — leaving  the  patient  feeble  and  prostrate.  As 
the  fever  subsides  the  eruption  disappears,  the  pains  in  the 
muscles  and  joints  abate  and  moisture  appears  on  the  skin.  The 
duration  of  this  stage — the  stage  of  remission — is  from  two  to 
three  days;  occasionally  it  is  so  short  as  to  be  overlooked. 

The  exacerbation,  or  second  febrile  paroxysm  occurs  on  the 
fifth  or  sixth  day  of  the  disease.  Its  onset  is  announced  by  the 
re-appearance  of  the  acute  symptoms.  The  temperature  again 
rises,  but  the  fever  is  remittent  rather  than  continued  in  char- 
acter. Simultaneously  with  the  elevation  of  temperature,  a 
scarlatinal,  erythematous,  or  roseola-like  eruption  makes  its  ap- 
pearance. This  exanthem  shows  itself  first  upon  the  palms  of 
the  hands  or  upon  the  soles  of  the  feet,  and  soon  spreads  over 
the  entire  body.  It  is  attended  by  a  troublesome  itching,  and 
after  remaining  from  a  few  hours  to  two  or  three  days,  vanishes 
in  a  furfuraceous  desquamation.  The  fever  now  gradually  sub- 
sides, and  the  acute  symptoms  disappear,  and  the  patient  passes 
on  to  convalescence. 

Dnration. — Dengue  is  a  self -limited 'affection,  appears  fre- 
quently in  distinct  types,  and  has  an  average  duration  of  about 
eight  days.  Relapses  after  an  interval  of  two  or  three  weeks 
frequently  occur.    These  are  always  milder  than  the  primary  at- 


i  I 
i  i 

1     :l 


i 


mtunn-- 


106 


LECTURES  ON   FEVERS. 


tack,  and  closely  resemble  an  attack  of  articular  rheumatism. 
Complications  seldom  arise,  and  sequels  are  rare.  Dr.  Forrest, 
of  Charleston,  mentions  excessive  and  obstinate  prostration, 
sleeplessness,  an»mia,  neuralgia,  boils  and  carbuncles,  aphonia, 
bronchial  catarrh,  rheumatism,  and  temporary  paralysis  of  th^ 
lower  limbs,  as  possible  sequels. 

ANALYSIS  OF  CHART. 

The  Nervous  System.— The  headache,  during  the  fever  es- 
pecially, involves  the  forehead  and  temples.  Restlessness  and 
sleeplessness  are  generally  present  during  the  first  and  third 
stages.  Sometimes  nocturnal  delirium  occurs.  In  children  con- 
vulsions are  prone  to  appear,  and  occasionally  cause  a  fatal 
termination. 

The  Cutaneous  System.— In  the  majority  of  cases  a  primary 
and  a  secondary  exanthem  occurs.  The  primary  exanthem  la 
not  as  constant  a  manifestation  as  is  the  secondary  exanthem. 
When  present  it  appears  and  disappears  simultaneously  with 
the  fever.  The  secondary  exanthem  is  as  a  rule  always  encount- 
ered. It  may  assume  various  and  occasionally  mixed  forms.  In 
children,  blotches  resembling  urticaria  are  frequently  seen,  and 
at  times  considerable  swelling  of  the  skin  attends  the  eruption. 
Ab  the  fever  subsides  bran-like  desquamation  usually  takes 
place.  In  exceptional  cases  the  desquamation  may  be  flaky  in- 
stead of  furfuraceous.  In  very  rare  cases  the  mucous  membrane 
of  the  throat,  mouth,  and  nose  becomes  inflamed  and  ulcerated. 
During  convalescence,  boils  and  extensive  subcutaneous  ab- 
scesses occasionally  occur. 

The  Glandular  System.— The  parotids  are  frequently  swollen, 
and  the  glands  about  the  groin  and  axilla  become  transiently 
enlarged.  In  severe  cases  along  with  enlargement  of  the  epi- 
didymis, serous  effusion  may  take  place  into  the  tunica  vagina- 
lis. 

The  Digestive  System.— Thirst  and  anorexia  accompany  the 
whole  course  of  the  disease.  The  taste  is  disordered  and  the 
tongue  becomes  coated  with  a  white  or  greenish-yellow  fur.  The 
patient  complains  of  nausea  with  pain  in  the  epigastrium,  and 
occasionally  vomiting.  In  the  early  stages  there  is  constipation 
with  a  tendency  to  hepatic  torpor  or  slight  congestion.    Later  in 


MaMMM^OMWaMWHI 


HMM 


CHART. 

CHAKT  \.—Denf)ve. 


107 


Eight  duys. 


Intense  headache.        Acute  pain  In  small  Joints. 


Invasion, 


2  to  3  days. 


Intense    frontal  headache. 
Sleeplessness. 


Kcmis'ion, 


13  hours 
to  3   days 


E.\acerbation. 


3  to  3  days. 


Staring    expression. 
Photophobia. 


106»  to  108", 


120  to  140, 


28  to  80  -per  minute, 


Primary  exanthem, 
scarlatinal. 


Glandular  swellings. 

especially  of  inguinal  glands, 

and  epididymis. 


Boring  pain,  and  stifCncss  in 
joints  and  limbs. 


Coated,  silver-white  or 
greenish-yellow. 


Thirst.    Nausea. 
Bilious  vomiting. 


S 
o 
^^ 

h 

«  a) 

IS 


SS 

■a 


Headache. 
Extreme    nervousness. 


Conjunctivitis. 
Photophobia. 


105»  to  107° 


120  to  140. 


23  to  26  per  minute. 


Secondary  exanthem, 
scarlatinal,   erythematous 

or  roseola-like. 
Branny  desquamation. 


Glandular  swellings.  Bolls. 


Pains  and  stiffness. 
Loss  of  strength  in  legs. 


Constipated, 


Scanty  and  dark, 
sp.  gr.  high. 


Augmnt'd 


Thickly  coated. 


Nausea.    Rarely  vomiting. 


Frequently  diarrhea. 


Scanty  and  dork. 


Always  favorable. 


Frequently  protracted.                    <„!„♦« 
with  extreme  debility,  stiffness  and  soreness  of  the  Joints, 
and  great  emaciation. 


Prom  two  to  seven  months. 


the  disease  the  constipation  may  disappear,  after  a  crisis  marked 
by  diarrhea. 

The  Extremities.— The  affection  of  the  joints  and  limbs  at- 
tacks large  and  small  joints  alike.  The  joints  of  the  hand,  foot 
and  knee  are  first  attacked,  then  the  spine,  and  lastly  the  joints 


1U8 


LECTURES  ON  FEVEK8. 


of  the  elbow  and  shoulder.  In  severe  cases  all  the  joints  be- 
come involved.  The  peculiarities  of  gait  and  attitude  caused 
by  interference  with  the  natural  movements  of  the  limbs  have 
oiven  to  tliis  disease  many  of  its  synonyms.  The  affected  joints 
are  swollen,  red,  immobile,  painful  and  highly  sensitive  to  the 
touch  The  muscles  are  stiffened  and  sore,  and  the  tendons  are 
somewhat  swollen.  The  pains  are  characterized  as  rheumatic  or 
rheumatoid,  and  tend  to  pass  from  one  joint  to  another  with 

great  rapidity.  ,.  .     ,  j     n 

After  the  second  paroxysm  the  joint  disturbance  gradually 
disappears.  Ofttimes  it  lingers  for  several  weeks  and  may  be- 
come  localized.  Extreme  debility  and  loss  of  muscular  power, 
more  particularly  in  the  legs,  may  continue  far  into  the  convales- 
cence. 

Differential  Diagnosis.— In  the  first  paroxysm,  or  stage  of 
invasion,  this  fever  may  be  confounded  with  acute  articular  rheu- 
matism.   In  the  second  paroxysm,  or  stage  of  exacerba,tion,  it 
bears  a  Btriking  likeness  to  scarlet  fever  or  measles.    In  its  gen- 
eral course  it  strongly  resembles  spirillum  or  relapsing  fever. 
From  rheumatism  it  may  be  distinguished  by  the  cutaneous 
eruption  and  the  epi  Jemio  character  and  rapid  spread  of  the 
disease.     From  scarlet  fever  it  may  be  distinguished  by  the  per- 
sistency of  the  rheumatic  and  neuralgic  pains,  as  well  as  by  the 
natural  course  of  the  affection.    And  from  relapsing  fever  it 
may  be  differentiated  by  the  eruption,  the  character  of  the  re- 
missions, and  the  absence  of  spirilla  in  the  blood. 

Prognosis.— The  prognosis  is  always  very  favorable.  A  fatal 
termination  is  an  exceptional  occurrence,  and  appears  mostly  at 
the  extremes  of  life. 

Treatment.-Prop%tois.-Iligid  quarantineof  infected  dis- 
tricts and  the  complete  isolation  of  patients  are  absolutely  neces- 
sary to  prevent  the  rapid  spread  of  dengue. 

Did  —The  diet  should  be  most  nutritious,  and  frequent  feed- 
ing will  prove  very  beneficial.  Hot  drinks  during  the  fever  are 
grateful  to  the  patient  and  tend  to  excite  free  perspiration,  a 
state  greatly  to  be  desired.  During  convalescence  alcoholic 
stimulants  should  be  given. 

Principal  Eemedies.-In  the  first  stage,  aconite  either  alone 
or  in  alternation  with  belladonna  or  bryonia  has  been  found 


LEADING   INDICATIONS. 


109 


ints  be- 
caused 
bs  have 
d  joints 
to  the 
ions  are 
uatio  ox* 
ler  with 

radually 
may  be- 
:  power, 
onvales- 

stage  of 
iar  rheu- 
aation,  it 
1  its  gen- 
ig  fever, 
utaneous 
d  of  the 
irthe  per- 
as  by  the 
g  fever  it 
>f  the  re- 

A  fatal 
mostly  at 

tected  dis- 
fily  neces- 

uent  f eed- 

3  fever  are 

piration,  a 

alcoholic 

bher  alone 
een  found 


most  beneficial.  In  the  second  stage,  arsenicum  alb.,  bryoma. 
rbns  ven.,  nuxvom..  puis.,  or  sulphur  will  be  mostfrequen  ly  m- 
dicated,  In  the  third  stage,  fielsemium  takes  the  place  filled  by 
aconite  in  the  first  stage.  During  convalescence  either  cinchona 
or  nux  vom.  may  be  needed.  Hot  mustard  foot-baths  at  the  on- 
set  of  the  fever,  are  highly  recommended.  The  annoying  itch- 
incr  which  attends  desquamation  at  the  close  of  the  second 
paroxysm  may  be  relieved  by  the  application  of  a  one  per  cent, 
solution  of  cLbolic  acid,  while  the  stiffness  and  soreness  of 
the  muscles  and  joints  which  tend  to  linger  and  thus  protract 
convalescence,  will  be  best  treated  by  eithermassage  or  the  mild 
galvanic  curreni 

Leading  Indications-Aconite.-In  the  first  paroxysm  when 
there  is  high  fever,  great  restlessness  and  anxiety.  fuU   hard 
quick  pulse;  pain  in  the  forehead  f  ^ *f ^^^^^  ^;*'  P^""'^"'^ 
swelling  of  the  joints.    It  is  followed  well  by  belladonna. 

Belladoniia.-Especially  adapted  to  dengue  in  children,  and 
when  either  the  congestive  or  throat  symptoms  predominate. 
Eves  are  red  and  glistening;  staring  pupils.  Bed.  shining  swell- 
S^of  the  joints.  Pains  running  from  the  affected  joints  along, 
the  limbs  like  electric  shocks. 

Bryoiiia.-Neuralgicand  rheumatic  pains,  worse  on  motion. 
FaSsh  streaky  redness  of  the  joints.    Pain  m  the  eyes  when 
mo^ng  them.    Lss  of  appetite,  white  coated  tongue,  f  ulhies. 
and  oppression  in  the  pit  of  the  stomach  and  bowels. 

Enpatorinm  perf.-Has  been  highly  recommended  i^t^e  first 
stage  The  bones  ache  as  if  broken.  Painful  soreness  of  both 
Ss  as  if  broken.  The  tongue  is  thickly  coated  yellow  ^d 
Ze  is  thirst  with  vomiting  after  drinking.  The  region  of  the 
Uver  is  sore  on  pressure,  and  there  is  great  tenderness  in  the 
epigastrium. 

«el8emiiim.-In  the  stage  of  exacerbation,  and  in  asthenic 
types  of  the  fever  generally.  There  is  intense  muscular  pros- 
Stion  Great  languor  and  drowsiness.  Heavy  suffused  eyes 
^rer^^ti^n  resembling  measles.  Giddiness  with  loss^of 
Bight  Bruised  pains  in  the  muscles,  general  rheumatac  symp- 
toms The  tongue  is  coated  whitish  or  yellowish,  and  there  is  a 
sticky  feeling  in  the  mouth. 


ii' 


M 


110 


LECTURK8  ON  FEVEBS. 


Hyoscyamus.— For  the  extreme  nervousness  and  sleeplessneBB. 

Mercnritts.— Is  occasionally  indicated  when  there  is  swelling 

o!  the  glands  of  the  neck.    The  pains  in  the  joints  are  tearing, 

worse  at  night  and  in  warmth  of  the  bed.    Diarrhea  especiaUy 

toward  evening. 

Pulsatilla.— Is  often  indicated  during  the  remission,  and 
when  the  pains  are  relieved  by  a  critical  discharge.  The  pains 
are  of  a  drawing,  tearing  character  and  frequently  shift  from 
one  part  to  another.  All  symptoms  are  worse  toward  eyemng, 
and  at  night  in  a  warm  room;  better  from  changing  position  and 
uncovering  the  affected  parts.  The  tongue  is  moist  and  coated, 
and  there  is  a  bad  taste  in  the  mouth.  Diarrheaic  stools  at  night. 
Urticaria.     Epididymitis. 

Rhus  Tenenata.— Is  one  of  the  most  useful  and  oftenest  in- 
dicated remedies,  after  aconite.  The  guiding  symptoms  are 
those  of  the  skin  and  mucous  membrane.  There  may  be  excess- 
ive parotid  inflammation,  especially  on  the  left  side.  The  ax- 
illary glands  are  inflamed  and  swollen.  The  eruption  is  dark- 
colored.  There  are  drawing,  tearing  pains  in  the  jomts  with  a 
sense  of  lameness  and  formication  in  the  affected  parts.  The 
pains  are  worse  during  rest  and  when  commencing  to  move;  they 
are  relieved  by  continued  motion  and  by  dry  external  warmth. 
Jerking,  tearing  pains  in  the  elbow  and  wrist  joints.  Paralysis 
of  the  lower  extremities. 


■,,■■11   iiiB^imiBWimii'' 


tlessness. 

swelling 
)  tearing, 
specially 


ions  and 
Dhe  pains 
lift  from 
L  evening, 
ntion  and 
id  coated, 
,  at  night. 

iienest  in- 
ttoms  are 
be  excess- 
Tlie  ax- 
a  is  dark- 
nts  with  a 
krts.  The 
love; they 
I  warmth. 
Paralysis 


s  LECTUBE  VIII. 

Typho-Malarial  Fever. 

We  now  come  to  the  study  of  typho-malarial  fever,  a  disease 
that  has  attracted  much  attention  since  the  late  civil  war.  Its 
relations  are  somewhat  peculiar,  in  that  it  presents  many  ele- 
ments in  common  with  typhoid  fever,  and  many  which  ally  it  to 
remittent  fever. 

Definition. — It  is  a  miasmatic  disease  due  to  the  combined 
action  of  a  malarial  and  a  septic  poison,  and  may  appear  in  two 
at  times  distinct,  and  at  other  times,  imperceptibly  blended 
types.  The  first,  or  malarial  type,  is  ushered  in  by  a  distinct 
chill,  and  is  characterized  by  a  rapid  rise  of  temperature,  a  ten- 
dency to  tertian  periodicity,  predominance  of  gastric  symptoms, 
abdominal  tenderness  and  diarrhea,  and  the  presence  of  free  pig- 
ment in  the  blood;  it  usually  terminates  in  recovery,  amend- 
ment gradually  taking  place  between  the  10th  and  20th  days. 
The  second,  or  septic  type,  is  marked  by  a  more  decided  typhoid 
tendency,  more  hepatic  tenderness  and  splenic  enlargement,  an 
icteroid  hue  of  the  skin,  dark  foetid  evacuations,  more  abdominal 
tenderness,  and  an  increased  amount  of  free  pigment  in  the 
blood.  In  fatal  cases,  at  the  close  of  the  second  week,  the  pa- 
tient passes  into  ^  state  of  stupor,  followed  by  coma  and  death. 
In  cases  that  are  to  recover,  at  the  end  of  the  second  week  the 
tongue  begins  to  clean,  and  the  gastric  and  intestinal  symptoms 
gradually  subside.  Convalescence  is  slow  and  tedious.  After 
death,  pathological  lesions  are  found,  which  closely  resemble 
those  of  typhoid  fever  on  the  one  hand,  and  remittent  fever  on 
the  other.    Typho-malarial  fever  is  non-contagious.  m 


112 


LECTURES  ON   FEVERS. 


Synoiiyins.-Itha«  been  variously  termed  entero-miasmatic 
fever  remitto-typhuB.  camp  fever,  and  Chickahommy  fever. 

History  .-Typho-malarial  fever  is  most  prevalent  in  malana 
districts,  and  more  especially  during  the  autumnal  season.    It 
"i  largely  am'ng  the  United  States  troops  dunng  the 
war  of  the  rebellion,  and  was  the  great  Bcourge  of  the  army  of 
the  Potomac  in  the  Peninsular  campaign  of  IHbA 

Etiology.-ThoiTue  nature  of  the  poison  of  typho-malarial 
fever  is  uinown.    It  is  however  generally  believed  to  have  a 
doubleorigin;partof  themorbific  agent  being  supplied  by  mala- 
ria  and  part  by  some  other  poison,  septic  in  character  of  which 
r^^isthetype.    With  such  a  dual  character  this  mo^xfic 
agent  may  give  rise  to  two  types  of  fever,  according  as  one  or 
the  other  element  predominates.    Hence  we  speak  of  a  sqp  c 
and  of  a  malarialiy^e  of  typho-malarial  fever.    Oftentimes  he 
distinguishing  lines  between  these  two  typesare  not  sharply  de- 
fined, and  frequently  the  symptoms  of  the  one  become  almost 
imperceptibly  mingled  veith  those  of  the  other 

Typho-malarial  fever  is  non-contagious.  Itis  a  disease  solely 
of  malarial  disiricts.  and  prevails  only  when  ank-hygienic  con. 
ditions,  such  as  over-crowding  and  bad  sewerage  exist  to  favor 
the  development  of  the  septic  element. 

Clinical  Hl8tory.-The  clinical  history  embraces  adescrip- 
tion.  first,  of  that  type  in  which  the  malarial  element  prevails, 
and  then  of  the  form  in  which  the  septic  element  is  predomi- 

nant. 

The  Malarial  Type.— The  premonitory  symptoms  of  this  type, 
when  present,  are  those  of  malaise,  headache,  loss  of  appetite, 
and  wandering  pains  in  the  back  and  limbs.  At  this  stage  the 
countenance  frequently  presents  a  yellowish  or  clay-colored 

aspect. 

The  attack  is  usually  ushered  in  by  a  distinct  chill  or  general 
coldness,  which  bears  a  marked  resemblance  to  the  chill  of  sim- 
ple remittent  fever.  Following  the  chill,  which  varies  in  dura- 
tion  from  half  an  hour  to  an  hour,  active  febrile  symptoms  ap- 
pear,  and  the  temperature  rises  in  a  few  hours  to  103  Fahr.  or 
104°  Fahr.  The  excretions  are  all  checked,  and  the  skin  becomes 
hot,  dry  and  harsh.  The  pulse  reaches  100  and  is  full  and  forcible. 


mtmitm 


CLINICAL  HISTORY. 


113 


f 


liasmatio 
fcver. 

I  malarial 

m.    It 

ing  tbe 

army  of 

malarial 
to  have  a 
by  mala- 
of  which 
I  morbific 
as  one  or 
a  septic 
itimes  the 
larply  de- 
ne almost 

sase  solely 
ienio  con- 
st to  favor 


a  descrip. 
t  prevails, 
I  predomi- 

f  this  type,, 
f  appetite, 
I  stage  the 
ay-colored 

or  general 
dll  of  sim- 
B  in  dura- 
iptoms  ap- 
'  Fahr.  or 
in  becomes 
d  forcible. 


The  patient  is  restless,  sleepless  and  incapable  of  mental  exertion. 
Between  sleeping  and  waking  there  may  be  slight  delirium. 
The  tongue  is  at  first  pale  and  flabby,  then  moist  and  covered 
with  a  whitish  yellow  fur.  After  a  time  it  becomes  dry  and  red 
and  sordes  may  collect  upon  j;he  teeth  and  lips.  As  the  fever 
advances,  nausea,  vomiting,  and  epigastric  tenderness  become 
more  marked.  In  many  instances  diarrhea  precedes  the  initial 
chill;  in  the  majority  of  cases  it  is  present  during  the  fever. 
Early  in  the  disease  there  is  abdominal  tenderness,  especially  in 
the  right  diao  fossa.  A  decided  tendency  to  tertian  periodicity 
exists  throughout  the  entire  course  of  the  fever. 

In  fatal  cases,  as  the  patient  enters  the  second  week,  or  some- 
times later,  symptoms  of  the  typhoid  state  appear;  the  prostra- 
tion rapidly  increases;  the  pulse  becomes  frequent  and  feeble; 
the  patient  passes  into  a  state  of  stupor;  the  tongue  becomes 
dry  and  fissured,  and  is  protruded  with  difficulty;  the  fteces  and 
urine  escape  involuntarily,  or  the  urine  may  be  retained;  and 
there  may  besubsultus  tendinum  and  carphologia;  gradually  the 
stupor  deepens  into  coma,  and  death  takes  place. 

In  favorable  cases  the  symptoms  begin  to  ameliorate  between 
the  tenth  and  twentieth  days;  the  temperature  steadily  declines 
p.nd  the  pulse  becomes  less  frequent  and  fuller;  the  nervous 
symptoms  improve;  the  tongue  becomes  clean,  the  thirst  dimin- 
ishes, and  the  appetite  returns;  the  abdominal  symptoms  sub. 
side,  and  the  patient  enters  upon  a  protracted  convalescence. 

The  Septic  Type. — The  initial  symptoms  of  this  type  are  those 
of  general  malaise,  with  headache,  and  pains  in  the  back  and 
limbs.  Usually  the  febrile  symptoms  are  ushered  in  with  either 
a  distinct  chill,  or  a  complete  intermittent  or  remittent  paroxysm ; 
following  the  chill,  the  temperature  rise  may  be  either  sudden 
or  gradual;  it  may  reach  104"  Fahr.  or  105°  Fahr.  within  twenty- 
four  hours,  or  not  until  the  eighth  or  tenth  day.  A  tertian  or 
quartan  periodicity  runs  through  the  whole  course  of  the  disease. 
The  pulse  is  full  and  frequent,  and  averages  about  100  beats  per 
minute  during  the  early  days  of  the  fever;  later,  it  becomes 
small  and  compressible  and  may  range  from  110  to  130  per  min- 
ute. Th  headache  becomes  continuous,  and  as  the  fever  pro- 
gresses gives  place  to  a  muttering  delirium;  the  sleep  is  much 
disturbed,  and  there  is  great  lack  of  mental  vigor;  occasionally 


114 


LECTURES  ON  FEVEBS. 


Bubsultus  tendinum,  and  carphologiii  a})pear.  The  skin  becomes 
dry  and  ussuines  a  bronzed  or  jaundiced  hue.  The  lips  are  dry 
and  parched.  The  tongue  is  at  first,  moist,  swollen  and  covered 
with  a  whitish  fur;  after  a  time  it  becomes  dry,  cracked  and 
fissured.  The  urine  grows  scanty.and  higli-colored.  The  stools, 
which  tend  to  increase  in  frequency  as  the  disease  advances,  are 
fetid,  watory,  and  generally  dark-colored.  The  abdomen  is  rarely 
distended;  frequently,  it  is  somewhat  retracted;  it  is  tender  to 
pressure,  i)articularly  over  the  ileo-cajcal  region. 

In  fatal  cases  as  the  patient  reaches  the  second  or  third  week, 
the  symptoms  closely  resemble  those  of  fatal  typhoid  fever;  the 
pulse  now  becomes  irregular  and  feeble;  the  prostration  steadily 
increases;  the  fsBces  and  urine  escape  involuntarily  or  the  urine 
is  retained,  and  the  patient  passes  into  a  state  of  stupor,  which 
deepens  into  coma,  and  ends  in  death. 

In  favorable  cases  improvement  sets  in  obout  the  twelfth  or 
fourteenth  day;  the  tongue  becomes  moist  and  begins  to  clean, 
gradually,  from  the  edges  to  the  center.  A  renewal  of  the  fever 
symptoms  is  sure  to  occur,  when,  after  the  coating  is  thrown  off 
in  flakes,  the  tongue  assumes  a  beefy  red  appearance,  and  again 
becomes  dry  and  brown.  As  recovery  progresses,  the  abdominal 
symptoms,  with  the  exception  of  the  diarrhea  begin  to  subside; 
the  pulse  becomes  slower  and  the  temperature  range  steadily 
approaches  the  normal;  the  appetite  improves;  the  strength 
gradually  returns;  and  the  patient  enters  upon  a  tedious  conva- 
lescence, liable  to  be  disturbed  by  complications  and  sequels. 

Typho-malarial  fever,  when  occurring  amongst  the  poorly  fed 
and  illy  clad,  who  live  in  badly  ventilated  apartments,  frequently 
takes  on  a  low  type  and  is  attended  by  neuralgic  and  arthritic 
pains  in  various  parts  of  the  body,  and  at  times  displays  a 
hemorrhagic  tendency,  marked  by  bleedings  from  the  gums  and 
mucous  surfaces.  In  such  cases  death  may  be  caused  during 
the  course  of  the  disease  by  hemorrhage  from  the  mucous  sur- 
faces; and  even  after  convalescence  appears  to  be  established  an 
uncontrollable  diarrhea  may  set  in,  and  by  exhaustion  lead  to  a 
fatal  result. 

Complications. — The  most  frequent  complication  of  typho- 
malarial  fever  is.  inflammation  of  the  respiratory  organs;  it  may 
take  the  form  of  either  a  troublesome  bronchitis,  or  a  catarrhal 


ANALYSIH  OF  CHAIIT. 


116 


lin  becomes 
lips  nre  dry 
[nd  covered 
rnckod  and 
[The  Htoolu, 
Ivnnces,  are 
len  is  rarely 
Is  tender  to 

third  week, 
1  fever;  the 
ion  steadily 
r  the  urine 
ipor,  which 

i  twelfth  or 
ns  to  clean, 
the  fever 
thrown  off 
),  and  again 
i  abdominal 
to  subside; 
ige  steadily 
be  strength 
[ious  conva- 
i  sequels. 
I  poorly  fed 
,  frequently 
id  arthritic 
displays  a 
e  gums  and 
sed  during 
ucous  sur- 
ablished  an 
n  lead  to  a 

of  typho" 
ins;  it  may 
»  catarrhal 


pneumonia.  So  often  is  it  the  complicating  lesion,  that  when- 
ever any  suddon  variation  in  temperature  occurs  during  the 
course  of  the  fever,  lung  trouble  moy  be  BU.^pect<'d,  and  a 
thorough  phyBicttl  exploration  of  the  chest  should  be  instituted. 
HeriouB  abdominal  complications,  such  as  intestinal  perforation, 
peritonitis  and  hemorrhage,  are  rarely  met  with  in  this  fever. 

Duration. — The  average  duration  of  typho-malarial  fever  ia 
from  three  to  four  weeks.  The  malarial  variety  is  alwoy  s  shorter 
than  the  septic.  Relapses  may  occur  at  any  period  during  con- 
yalescence. 

ANALYSIS  OF  CHAIIT. 

The  NerTOUS  System. — Headache  is  one  of  the  earlier  and 
more  constant  symptoms.  It  often  precedes  the  ushering-in 
chill.  It  is  most  severe  in  the  first  week,  and  passes  into  mut- 
tering delirium  as  the  fever  progresses.  In  many  instances  the 
delirium,  if  mild,  occurs  only  at  night,  and  in  all  cases  it  is  more 
marked  during  the  night  time.  In  advanced  stages  of  se- 
vere cases,  subsultuB  tor  din um,  picking  at  the  ^ed-clothest 
and  vague  graspings  in  the  air  are  observed.  Neuralgic  and 
arthritic  pains  in  the  back  and  limbs  are  commonly  present  in 
cases  modified  by  anti-hygienic  surroundings.  With  deferves- 
cence there  is  great  lack  of  mental  vigor,  and  a  tendency  to  men- 
ial sluggishness. 

The  Digestive  Tract. — The  tongue  at  first  is  somewhat 
swollen,  and  covered  with  a  thin,  whitish  fur.  As  the  typhoid 
state  increases,  it  becomes, dry,  brown,  and  fissured.  In  graye 
cases  sordes  collect  upon  the  teeth  and  lips.  The  appetite  is 
greatly  disturbed  from  the  start,  and  is  wholly  lost  when  the 
tongue  becomes  brown  and  dry.  In  mild  cases  when  the  tongue 
retains  its  moisture,  the  loss  of  appetite  may  be  only  partial. 
Nausea  and  vomiting,  and  epigastric  tenderness  are  present  in  a 
greater  or  less  degree  in  all  cases.  The  matters  vomited  usually 
consist  of  food,  or  of  gastric  mucus  stained  green  with  bile. 
Diarrhea  is  a  common  symptom  and  may  occur  at  any  period. 
It  is  seldom  excessive  before  the  second  orlihird  week.  The 
stools  are  generally  fetid,  watery,  and  dark-colored.  At  times 
they  are  of  a  dark  clay  color.  With  the  diarrhea  there  is  more 
or  less  abdominal  tenderness,  especially  in  the  right  iliac  region. 
Tympanites  is  seldom  marked.    Hemorrhage  from  the  bowels 


iriiilibJIIilllllUIIIMIIIWI 


f 


wm 


116  LECTUREa  ON   FEVlCim. 

CHAllT  YL-Typho-MnlarUil  Frtur. 


Natun*: 

Nnn-oontairloiii. 

EtInUivy; 

A  (liiiil  inorbiflo  ngfnt— (n>pUo  uml  miilarlkl.) 

Pi-riod: 

FIrtit  w<M'k, 

rteeiiiid    week,            i          Thlnl  week, 
(and  oxeeptlonnlly  the     (nndexe<>ptlonully  ihi' 
third  )                  \             fourth.) 

liiltliil 
•yniptiiiiiH: 

A  ohill  or  malarial  panixyim. 

NlTVlUlH 

nyntvtn: 

IliMiilachc, 
KimtlcHMiKmi*, 

HUM'pll-HRMfKN, 

Active  or  Miutlerlilg 

delirium.    BubKultuHten- 

dlnum.  rarphologlu. 

Delirium  dlsap|H'ui'« 

or  passes  Into 

stti|ior  and  einiin. 

Moist  as  con  vales-  , 
conco  setH  In. 

Tnnmio: 

HwolU'li. 

Kod  piiplllic     Whltr 

cimtlnH:. 

Dry  and  brown. 

Htomaoh: 

Anoruxlii, 
Nniidon.    Vnmitlnir. 

Kplgaitric  tenderness. 

Hulls  Idenee 
of  symptoms. 

^Jloweli: 

Fetid,  watery,  dark  oviifuatliina; 
•t  tlmen  ooimtlputloii. 

AlHlnmen: 

Hllgbt  tendornoM  In  rlirht  illau  foHHa.  Itetrautton. 
TympanUi'H  rant. 

PuIbu: 

100.  Full  and  forcible, 

110  to  130 
Small,  oompresslhlo. 

Slower  or  faster. 

llradiiiilorRiid'nrtBe,         HcmUfilnng  ttvery 
TcmiMiriitim.'            los"  to  KB",                         2.1  or  8d  iliiy, 

(IraduHlly  HpproHehe)> 
the  noniial. 

Faw: 

Waxy,  clay-oolored  or  yollowlHb. 

Sktn: 

Bronzed,  or  lutorlu  hue. 

DlcKMl: 

Free  pigment  »frunuleg. 

Urine: 

1 

Scanty,  dark-colored,  turbid. 

Incn-ased. 

Liver: 

Enlarged.    H(n>atlo  tendcriiesH. 

Splocii : 

Enlarged.    Pigmented.    Diiik. 

duration: 

Two  to  four  weeks. 

Complications: 

Bronchitis  and  catarrhal  pneumonia. 

. 


occasionally  occurs  and  may  cause  death  from  exhaustion.  When 
diarrhea  follows  ^e  subsidence  of  the  fever,  and  is  uncontroll- 
able, there  is  danger  of  its  leading  to  a  fatal  termination.  He- 
patic tenderness  is  a  well-marked  and  early  symptom.  Enlarge- 
ment of  the  spleen  takes  place  as  the  fever  progresses.  The- 
amount  of  enlargement  is  apt  to  be  greater  than  in  typhoid 
fever. 


■'Oavd. 


nla. 



I.  When 

controll- 
•n.  He- 
Snlarge- 
»s.  Th& 
typhoid 


MORDID  ANATOMY. 


117 


The  Temperature. — Tbo  temperature  ri&t^  is  apt  to  be  sud- 
<1on,  and  may  reach  103"  Fahr.  or  104  P^hr.  in  a  f«w  huars.  In 
tfonie  cases  the  rieo  is  gradual,  the  mnxirauui  nut  l>eiii^  raaclied 
before  the  tenth  day.  Well-marked  lur-moon  remissions  apjywir 
every  second  or  third  day. 

The  PulHe. — The  increase  in  the  frequency  '  'f  the  pulse  cor^ 
re8i)ondB  to  the  rise  in  tempttrature.  It  is  less  fro(iuent  in  the 
morning  than  in  the  evening.  During  the  first  week  it  is  full, 
and  rarely  exceeds  100.  During  the  second  and  third  weeks,  it 
is  small  and  compressible,  and  ranges  from  110  to  130.  During 
the  third  week  it  gradually  diminishes  in  frequency.  In  severe 
cases  it  is  apt  to  bo  frequent.  And  as  a  general  rule  a  steady 
range  above  120  renders  the  prognosis  somewhat  unfavorable. 

The  Cutaneons  Snrface.— The  skin  becomes  dry  and  harsh, 
and  assumes  a  bronzed  hue  shortly  after  the  onset  of  the  fever. 

Morbid  Anatomy. — The  pathological  changes  of  typho-mala- 
rial  fever  are  similar  to  those  which  occur  in  typhoid  fever,  and 
in  malarial  fever.  The  liver  is  increased  in  size,  and  its  cut  sur- 
face presents  an  appearance  analogous  to  that  of  nutmeg  liver. 
In  many  cases  it  is  softened,  and  upon  microscopical  examination 
shows  free  fat,  and  more  or  less  brown  pigment  in  the  hepatic 
«ells.  The  apleeti  is  enlarged,  softened  and  pigmented,  and  on 
section  is  of  an  almost  black  color.  The  changes  in  the  kidneys 
are  those  of  hypereemia  and  are  most  marked  in  the  cortical  sub- 
stance. The  heart  is  soft  and  of  a  pale,  yellowish,  or  faded-leaf 
color;  the  softening  is  due  to  a  granular  degeneration  of  the 
muscular  fibres.  The  blood  is  dark  colored,  and  contains  free- 
pifjment  granules.  The  inteatinal  changes  of  typho-malarial 
fever,  like  those  of  typhoid  fever  center  in  and  around  the  agmi- 
nate and  solitary  glands  of  the  ileum.  The  pathological  pro- 
cesses commence  at  the  lower  extremity  of  the  ileum  and  extend 
upwards.  The  glands  may  be  found  in  different  stages  of  de- 
generation. In  the  earlier  stages  they  are  enlarged  and  infil- 
trated by  an  excessive  proliferation  of  cellular  elements,  and  by 
a  dex)OBit  of  black  pigment,  and  the  mucous  membrane  presents 
ihe  appearance  of  catarrhal  inflammation.  Peyer's  patches  be- 
come thickened,  and  there  is  a  gradual  elevation  of  the  mucous 
membrane  surrounding  the  enlarged  follicles.  After  a  variable 
length  of  time,  ulcers  appear  at  the  summit  of  the  follicles. 


bBb 


118 


LE0TURE8  ON  FEVERS. 


\. 


i 


These  ulcers  differ  from  those  of  typhoid  fever,  in  that  they  pre- 
sent ragged,  irregular  and  extremely  undermined  edges, and  are 
more  or  less  pigmented.  They  may  involve  only  a  single  folli- 
cle, or  they  may  extend  into  the  submucous  tissue  and  attain  the 
size  of  from  half  an  inch  to  an  inch  in  diameter.  The  enlarged 
patches  rarely  present  the  umbilical  depression  prior  to  ulceration 
so  common  in  typhoid  fever.  Infostinal  perforation  as  a  result  of 
ulceration  is  an  accident  seldom  met  wi'^h  in  typho-malarial  fever. 
The  mesenteric  glands  will  usually  h?,  found  more  or  less  en- 
larged and  pigmented.  Small  ulcers  are  occasionally  met  with 
in  the  stomach  and  large  intestines.  And  if  ecurvy  complicates 
either  type,  ulcerative  changes  similar  to  those  found  in  chronic 
malarial  dysentery,  are  liable  to  occur. 

Differential  Diagnosis. — The  septic  type  of  typho-malarial 
fever  is  liable  to  be  confounded  Avith  typhoid  fever,  and  the 
malarial  type  with  simple  remittent  fever.  The  onset  of 
typho-malarial  fever  however,  is  apt  to  be  sudden  and  is 
marked  by  a  distinct  chill,  while  that  of  typhoid  fever  is  in- 
sidious, and  is  attended  only  by  a  chilly  sensation.  The  tem- 
perature rise  in  typho-malarial  fever  is  sudden,  and  follows, 
no  typical  range,  while  in  typhoid  fever  the  typical  range 
during  the  first  week  is  caaracteristio.  In  typho-malarial 
fever  there  is  a  distinct  periodicity  in  febrile  action  which 
does  not  appear  in  typhoid  fever.  Typho-malarial  fever  has 
no  characteristic  eruption,  while  typhoid  fever  has  a  rose- 
colored  eruption,  which  makes  its  appearance  about  the  seventh 
day.  The  individual  rose-colored  spots  of  typhoid  fever  kist 
only  three  days,  while  the  eruption  of  typho-malarial  fever, 
when  present,  remains  visible  throughout  the  whole  course  of 
the  fever.  In  typho-malarial  fever  the  skin  has  an  icteroid 
hue,  and  there  is  marked  hepatic  tenderness,  and  extensive- 
splenic  enlargement  The  stools  of  typho-malarial  fever  are 
non-infectious,  while  those  of  typhoid  fever  are  infectious. 
The  blood  in  typho-malarial  fever  contains  free  pigment,  while 
that  of  typhoid  fever  rarely  does. 

From  simple  remittent  fever,  typho-malarial  fever  may  bo 
differentiated  by  the  early  appearance  of  the  enteric  symptoms 
in  the  latter. 

From  typhus  fever,  it  ro-'v  be  diagnosed  by  the  presence  of 


tmsatismmmmKa 


rUINCirAL   ItEMEDIEH. 


119 


.  that  they  pre- 
edges,  and  are 
'  a  single  foUi- 
and  attain  the 
The  enlarged 
ir  to  ulceration^ 
nas  a  result  of 
malarial  fever, 
ore  or  less  en- 
nally  met  with 
vy  complicatea 
and  in  chronio 

typho-malarial 
fever,  and  the 
The  onset  of 
udden  and  is 
)id  fever  is  in- 
ion.  The  tem- 
a,  and  follows 

typical  range 
typho-malarial 
3  action  which 
arial  fever  has. 
)r  has  a  rose- 
out  the  seventh 
ihoid  fever  last 
-malarial  fever, 
Hrhole  course  of 
lias  an  icteroid 

and  extensive 
larial  fever  are 

are  infectious. 
I  pigment,  while 

I  fever  may  be 
iteric  symptoms 

the  presence  of 


abdominal  symptoms  which  are  absent  in  typhus,  and  by  the  ab 
sence  of  the  mulberry-rash  of  typhus.  *„,+  thnt  tho 

From  yclkm  fever,  it  may  be  distinguished  by  the  ^^^^^"^fj^; 
range  o/temp'erature  is  lower  in  the  former  than  in  the  latte. 
Yellow  fever  is  a  portable  disease,  typho-malarial  fever  is  en- 
demic and  non-portable.     In  yellow  fever  the  short  duration  ci 
the  disease,  the  Amission  on  the  third  or  fourth  day.  the  circum- 
orbital  paik.the  red  and  watery  eye  the  pecul-r  coW^ 
skin    the    projectile  vomiting,  the  black  vomit,   the  gaseous 
puls'e,  the  absence  of  diarrhea,  and  the  presence  of  albumen  in 
the  urine,  are  symptoms  sufficiently  diagnostic. 

Proirnosis.-The  prognosis  varies  with  the  habits  and  social 
cord?tfon"fthe  patiLt.'  The  average  ratio  oi^^^^^^^^- 
five  to  ten  per  cent.     The  septic  type  is  more  fatal  than  the  ma 
W  t™    Drunkenness  and  anti-hygienic  surroundings  lessen 
tte  chlSces  for  recovery.     The  prognosis  should  always  be 
luarded  Avhen  there  is  a  continued  high  temperature,  a  frequent 
feeble  fluttering  pulse,  a  profuse  diarrhea,  a  dry,  red  and  fissured 
t^nJue  Seat  df owsiness  and  a  tendency  to  stupor  and  coma  and 
Sprall^when,  during  the  third  week  of  the  fever,  capillary 
bronchitis  or  pneumonia  supervenes. 

Treatmeiit.-The  preventive  treatment  consists  in  the  first 
Place trt"  e  removaHrom  anti-hygienic  surroundings,  such  as 
oler^crowdng,  defective  sewerage  or  faulty  drainage ;  and  in 
:hrsecondpface.in  well  -gulat^^  and  nutri  jous  f  e^^^^^^ 
in  the  strict  observance  of  the  laws  of  health.    You  will  tre 
aueX  find  hapUsia,  1st  dil.  administered  morning  and  evening 
Tas  a  valuable  prophylactic  in  localities  where  typho-malanal 
fever  prevails. 

Principal  »emedies.-The  therapeutics  of  this  form  of  fever 
wiU  varv  with  the  type  of  the  fever,  and  the  peculiarities  of  each 
^LSrie.  The  septic  type  will  frequently  be  aborted  by 
thf  lively  use  of  hapUsiaj  and  the  malaria  type  can  be  materi- 
ally shorter  d  by  the  administration  of  ^f «  f  ^^^  '^ 
stace  of  invasion.  When  these  remedies  fail  to  cut  short  the 
SLe  before  the  end  of  the  first  week,  br^/onta  will  generally 
t  needed  And  if  in  from  two  to  four  days  no  improvemen 
al^s  bryonia  should  give  place  to  rhus  tax.,  and  especially  if 
JhTeTsdbrrhea  and  the  stools  are  black-brown,  and  mvolun- 


120 


LECTUBE8  ON  FEVEBS. 


ta^^^    Arsenicum  follows  well  after  rhus  tox.,  and  is  adapted  to 
the  second  and  third  weeks  of  the  fever.    For  hepatic  disturb- 
ances mercurius  will  frequently  be  needed.    Hyoscyamus,  stra- 
monium, or  belladonna,  will  prove    a  valuable  intercurrent 
remedy,  when  stupor  or  furious  delirium  supervenes.    Arnica 
is  indicated  as  an   intercurrent  when  there  are  involuntary 
discuarges  of  stool  and  urine.    When  the  pneumonic  symp- 
toms are  strongly  marked,  and  have  not  been  relieved  by  bry- 
onia,  and  there  is  a  violent  dry  racking  cough,  Phosphorus 
often  helps.    "  Stools,  black  like  coffee  dregs,"  is  an  additional 
indication  for  phosphorus.     Tart.  emet.  will  be  of  service  when 
there  are  mucous  rales,  and  threatened  oedema  of  the  lungs.    A 
tardy  convalescence  calls  for  either  Phosphoric  acid  or  cinchona. 
Baptisla.— Corresponds  with  the  first  7  or  10  days  of  the  fever, 
and  is  our  nearest  similimum  for  the  congestive  and  catarrhal 
changes  occurring  in  the  intestinal  tract  during  this  period.    It 
has  a  marked  action  to  clean  the  tongue,  and  causes  an  early  re- 
turn of  appetite.    A  soreness  on  lying,  and  a  sense  of  being  all 
to  pieces,  are  characteristics.    Typho-malarial  fever,  not  typhoid 
fever,  is  the  fever  that  is  "broken  up"  by  the  administration  of 
Baptisia;  as  typhoid  fever  will  run  its  typical  course  in  spite  of 
treatment 

Bryonia.— Stands  next  to  baptisia.  It  has  a  longer  action 
than  baptisia,  and  corresponds  to  forms  that  run  a  mild  or  mod- 
erately intense  course.  It  frequently  cuts  the  fever  short  at  the 
end  of  the  second  week  if  not  before.  Moderately  severe  cases 
frequently  need  no  other  remedy.  Nightly  delirium  does  not  in 
any  stage  contra-indicate,  but  on  the  contrary  is  an  additional 
indication  for,  bryonia. 

Rhus  tox.— Is  indicated  for  a  more  intense  character  of  the 
disease,  and  when  there  is  excessive  reactive  endeavor  with  in- 
sufficient reactive  power.  It  corresponds  to  all  the  stages,  but 
seldom  cuts  the  fever  short.  A  red  triangle  at-  the  tip  of  the 
tongue  is  characteristic. 

Arsenicnm  alb.— Follows  Rhus  well,  and  especially  if  the 
adynamic  state  is  strongly  marked.  Marked  remissions  of  the 
fever  are  quite  characteristic  of  this  remedy.  Weak  and  debili- 
tated individuals  frequently  respond,  as  if  by  magic,  to  the 
action  of  arsenic. 


hv, 


iiti 


HYGIENIC  AND  DIETETIC  TREATMENT. 


121 


the  fever, 

catarrhal 

jriod-    It 

early  re- 

beingall 

)t  typhoid 

tration  of 

n  spite  of 

[er  action 
d  or  mod- 
lort  at  the 
vere  cases 
oes  not  in 
additional 

ler  of  the 
r  with  in- 
tages,  but 
tip  of  the 

ly  if  the 
>ns  of  the 
nd  debili- 
ic,  to  the 


Oelsemiam. — Is  specially  useful  in  the  early  stages  of  the 
.malarial  type  of  tliis  form  of  fever.  There  is  great  nervous  rest- 
It  ssness,  and  muscular  weakness.  The  pulse  is  full  and  soft,  but 
not  very  rapid.  The  tongue  is  moist  and  coated  with  a  white 
fur.  After  the  end  of  the  first  week  either  arsenicum  or  bryonia 
will  be  needed  to  complete  the  cure. 

Mercurlns. — Isoftener  indicated  in  typho-malarial  fever,  than 
in  typhoid  fever.  An  icteroid  hue  of  the  skin,  hepatic  tender- 
ness, and  a  painful  sensibility  of  the  abdomen,  are  among  the 
more  prominent  symptoms.  Mercurius  is  never  indicated  when 
there  is  delirium  and  the  tongue  becomes  dry. 

Phosphorus. — Is  the  remedy  for  the  lung  complications,  and 
when  colliquative  diarrhea  occurs  as  a  sequel. 

Phosphoric  Acid. — Will  frequently  prove  useful  in  cases 
complicated  with  scurvy  ;  and  when  convalescence  is  protracted 
and  there  is  great  prostration. 

Additional  indications  for  these,  and  for  other  less  important 
remedies  for  typho-malarial  fever,  have  already  been  mentioned 
in  a  general  way  in  connection  with  the  treatment  of  malarial 
fevers.  They  will,  however,  be  specially  considered  when  we 
come  to  speak  of  the  treatment  of  typhoid  fever. 

HYOIENIC  AND  DIETETIC  TREATMENT. 

The  sick  room  should  be  large  and  well  ventilated.  The  tem- 
perature of  the  apartment  should  be  maintained  at  from  60°  Fahr. 
to  70°  Fahr.  Mental  quietude  is  extremely  important  If  the 
fever  runs  high  the  cold  bath,  as  recommended  by  some  of  our 
trriters,  if  used  at  all,  should  be  used  with  extreme  caution,  for 
lypho-malarial  fever  patients  do  not  always  stand  this  treatment 
well. 

The  best  drink  is  pure  water.  But  wine  and  water,  lemonade, 
iced  tea  with  lemon  juice,  or  thin  barley  water  are  all  grateful. 

The  diet  should  be  restricted  and  for  the  most  part  liquid.  It 
should  be  administered  with  regularity,  and  as  often  as  every 
hour  or  two  when  there  is  great  prostration.  Milk  occupies  the 
first  place  as  a  food.  It  may  be  given  either  raw  or  boiled.  But- 
ter-milk or  koumyss  may  be  given  occasionally  as  a  substitute 
for  milL  Beef  tea  or  chicken  broth  containing  a  little  barley  is 
very  nutritious  and  is  oftentimes  quite  palatable  to  the  patient 


122 


LECTURES  ON  FEVERS. 


The  addition  of  two  or  three  graiiis  of  pepsin*  to  each  cupful 
of  milk  or  broth  facilitateB  digestion.     Alcoholic  stimulants  are 
unnecessary  unless  there  are  signs  of  heart  failure.    In  the  ma- 
iority  of  cases  they  are  not  needed  before  the  end  of  the  second 
week     The  best  effects  are  obtained  from  claret  or  champape. 
Whisky  or  brandy  may  be  given  in  the  form  of  |"ilk  punch  or 
commingled  with  water.     During  convalescence  the  diet  should 
be  restricted  to  milk,  koumyss,  eggs,  custards,  farinaceous  foods, 
and  animal  broths.     At  the  end  of  a  week  solid  food  and  par- 
ticularly  meat  may  be  taken.    Milk  punch,  egg-nog,  and  wine 
are  often  of  service  during  convalescence.    And  as  early  as 
practicable  a  brief  journey  to  the  sea-shore,  or  at  least  a  change 
of  climate  and  scenery  will  aid  materially  in  bringing  abouc  a 
rapid  restoration  to  health. 

*Hawley'8  saccharated  pepsin  is  the  best.    Fairchild's  essence  of  pepsin 
stands  next. 


;h  cupful 
ilants  are 
1  the  ma- 
le second 
ampagne. 
punch  or 
et  should 
ous  foods, 
and  par- 
and  wine 
early  as 
;  a  change 
ig  above  a 

:e  of  pcpsia 


LECTURE  IX. 

Hay  Fever. 

TTnv  fever  mav  be  justly  dossed  among  the  miasmatic  dis- 
!^i,  It  is^aused  by  the  action  of  an  agent  which  originates 

"'"'S'.^dCrTl   -S»  variety  U  iB  addUiou  «>n. 

p^a.  B^dS^-  it  -e!  lea^g  behind  no  percephbla  ef - 

fects.  ij  T 

»^«AtiTms  -It  has  been  variously  named,  Rose  cold,  June 

eofZXS'B  catarrh.  Pollen  cata..h.  Pollen  asthma.  Hay 

Mthma.  Rye  asthma,  and  Catarrhus  ^stxvua. 

Hi8tory.-Hay  fever  had  its  birOi-place  in  England.  ^It  was 


124 


LECTUBE8  ON  FEVEB8. 


first  described  by  Bostock,  himself  a  victim,  in  1819.  In  1854 
Phoebus  of  Giessen,  gave  an  analysis  of  300  cases.  Dr.  Wyman, 
of  Harvard  University,  in  1872  described  the  disease  under  the 
name  of  autumnal  catarrh.  And  the  following  year  Dr.  Beard 
published  his  treatise  on  hay  fever  or  summer  catarrh.  More 
recently  Dr.  Blackley  has  given  to  the  profession  the  important 
results  of  his  experimental  studies,  extending  over  a  period  of 
ten  years.  Hay  fever  is  especially  prevalent  in  England,  and  is 
rapidly  becoming  a  common  disease  iu  the  northern  sections  of 
this  country. 

Etiology. — The  causes  of  this  affection  are  of  two  kinds, 
predisposing  and  exciting — 

1.  The  predisposing  causes: 

Hay  fever  is  a  disease  of  the  upper  classes  of  society,  and  phy- 
sicians are  frequent  victima  It  attacks  only  people  predisposed 
to  it,  and  mainly  such  as  are  of  the  Anglo-Saxon  race.  Nervous 
temperaments  are  particularly  susceptible.  The  degree  of  sus- 
ceptibility will  vary  in  different  individuals,  and  a  given  pollen 
may  be  highly  irritating  with  one  person  and  comparatively 
mild  with  another.  The  susceptibility  becomes  more  marked  in 
each  succeeding  year.  The  disease  attacks  individuals  under 
forty  years  of  age  only;  and  prevails  more  among  males  than 
females.  Hereditary  tendency  is  supposed  by  some  to  play  an 
important  part  in  its  causation. 

2.  The  exciting  causes: 

Hay  fever  appears  usually  in  early  summer  and  mid-summer. 
It  is  caused  by  the  presence  of  the  pollen  of  flowering  plants  in 
the  atmosphere,  and  its  irritant  action  on  the  respiratory  mucous 
membrane  of  susceptible  individuals.  The  time  of  flowering  of 
hay  grass,  Indian  com,  and  especially  of  the  rag-weed  (which 
begins  the  latter  part  of  August,  and  continues  through  Sep- 
tember) is  most  favorable  to  its  development.  The  pollen  be- 
longs to  the  non-coherent  class,  and  as  it  floats  in  the  air  is  dry 
and  shrivelled.  In  the  dry  as  well  as  in  the  fresh  state  it  is  ca- 
pable of  producing  all  the  symptoms  of  this  distressing  malady. 
The  pollen  of  plants  that  have  flowered  prematurely  does  not 
possess  the  activity  of  that  which  is  generated  later.  Tempera- 
ture exercises  an  important  influence  upon  the  production  as 
well  as  activity  of  pollen.  A  low  temperature  below  a  certain 
point  not  only  lessens  the  quantity  thrown  off,  but  also  causes 


lann 


CLINICAL  HISTORY. 


125 


In  1854 
Wyman, 
mder  the 
Beard 
More 
mportant 
period  of 
id,  and  is 
ictions  of 

wo  kinds, 


,  andphy- 
'edisposed 
Nervous 
'ee  of  6US- 
iren  pollen 
paratively 
marked  in 
lals  under 
Dales  than 
to  play  an 


d-summer. 
g  plants  in 
}ry  mucous 
owering  of 
)ed  (which 
ough  Sep- 
pollen  be- 
)  air  is  dry 
\te  it  is  ca- 
ag  malady, 
y  does  not 
Tempera- 
duckion  as 
V  a  certain 
ilso  causes 


that  which  is  generated  to  act  with  less  vigor.  Kainy  weather 
notably  diminishes  the  quantity.  Hence  hay  fever  patients 
sufier  less  in  cold  and  wet  summers  than  in  warm  and  com- 
paratively dry  seasons. 

The  disturbance  caused  by  the  pollen  is  due  partly  to  its  me- 
chanical effect  and  partly  to  the  physiological  action  of  its  granu- 
lar matter.  Blackley  thinks  that  the  sneezing  and  discharge  of 
serum  of  the  first  stage,  are  due  to  the  mechanical  changes  in- 
cident to  the  development  of  the  pollen  tube,  from  the  influence 
of  the  moisture  of  the  nasal  passages  on  the  pollen,  and  its  pene- 
tration into  the  mucous  follicle.  And  the  swelling  caused  by 
the  effusion  of  fluid  into  the  submucous  cellular  tissue  is  duo 
to  the  presence  of  some  substance  or  quality  in  the  granular 
matter. 

Hay  fever  attacks  are  more  violent  in  the  country  than  in  the 
city,  and  in  the  open  air  than  in-doors.  In  this  country  the 
disease  prevails  mostly  throughout  the  North,  while  nearly  the 
whole  of  the  Southern  States  is  entirely  free  from  ii 

Varieties. — It  may  exist  in  either  of  two  forms — the  catarrhal 
and  the  asthmaiic — and  eoch  form  is  made  up  of  three  stages — 

1.  The  stage  of  development:  which  lasts  from  one  hour  to  a 
few  days. 

2.  The  paroxysmal  stage:  of  three  or  four  weeks'  duration. 

3.  The  stage  of  convalescence:  of  short  duration. 

Both  varieties  may  exist  together,  or  either  one  of  them  may 
appear  alona 

Clinical  History. — The  catarrhal  form  runs  its  course  with, 
little  or  no  pain,  and  no  important  symptoms.  The  first  symp- 
tom is  generally  a  mild  or  severe  itching  in  the  fauces.  Eustachian 
tubes,  and  the  nostrils.  Violent  attacks  of  sneezing  soon  occur, 
followed  by  a  discbarge  of  thin  watery  serum  from  the  nostrils. 
The  nasal  mucous  membrane  swells  more  or  less  rapidly,  accord- 
ing to  the  ampunt  of  pollen  in  the  respired  air.  Frequently  the 
swelling  is  so  great  that  the  nares  are  closed.  If  the  patient 
takes  the  recumbent  position  on  the  side,  the  swelling  subsides 
in  the  nasal  passage  which  is  uppermost,  since  the  oedematous 
effusion  gravitates  towards  the  lowest  pari  As  the  height  of 
the  hay  season  approaches,  the  paroxysms  of  sneezing,  which 
have  hitherto  occurred  mostly  during  the  day,  are  apt  to  appear 


126 


LECTURES  ON   FEVERS. 


nlso  at  night.    After  a  time  the  sensibility  of  the  highly  swollen 
8chueiderian  membrane  becomes  lessened.    Later  the  membrane 
becomes  thickened,  and  ultimately  even  purulent.    The  eye 
symptoms  generally  follow  the  nasal  symptoms  and  are  initiated 
by  an  attack  of  itching.     As  the  season  progresses  the  itching 
becomes  more  troublesome,   and  is  frequently  attended  by  a 
slight  burning  sensation.    Occasionally  shooting  neuralgic  pains 
are  felt  in  the  back  part  of  the  orbit  and  in  the  eyeball.      In 
severe  attacks  the  eyelids  become  oedematous,  and  slight  che- 
mosis  is  established.    When  the  disease  is  fully  developed  the 
lachrymal  canals  and  nasal  ducts  become  almost  entirely  closed 
by  the  swelling  of  the  submucous  tissue.      The  discharge  is  at 
first  thin  and  watery,  then  thicker,  and  in  exceptional  cases, 
purulent    The  mucous  membrane  of  the  fauces  and  mouth  is 
not  as  sensitive  to  the  action  of  the  pollen,  as  that  of  the  nares. 
The  pharynx  is  the  seat  of  an  itching  and  slight  burning  or 
pricking  sensation.     The  itching  is  apt  to  be  severe  in  the  hard 
palate,  the  upper  part  of  the  pharynx  and  in  the  Eustachian 
tubes.     Sometimes  there  is  slight  deafness,  which  occasionally 
tends  to  linger.     Rarely  there  is  hoarseness  and  a  moderate 
cough.    The  chemosis  and  the  oedema  of  the  eyelids  are  gener- 
ally the  last  symptoms  to  disappear. 

The  asthmaiic  form  is  constantly  accompanied  by  laryngo- 
bronchial  catarrh,  and  in  many  of  its  symptoms  closely  resem- 
bles ordinary  asthma.  After  the  coryza  and  eye  symptoms  of 
the  ordinary  catarrhal  form  have  been  in  existence  a  variable 
length  of  time,  a  difficulty  of  breathing  appears.  Sometimes 
however  they  will  come  together.  The  first  symptom  of  an 
asthmatic  attack  is  a  sense  of  tightness  and  weight  across  the 
chest.  The  difficulty  of  breathing  is  greatest  during  the  night, 
but  may  be  somewhat  severe  during  the  after  part  of  the  day, 
from  the  increased  inhalation  of  pollen.  Patients  frequently 
complain  of  a  feeling  as  of  a  band  passing  around  the  head  above 
the  eyes.  After  the  catarrhal  symptoms  have  existed  for  some 
time  a  cough  appears.  In  some  cases  this  cough  is  moderate, 
and  is  attended  with  some  expectoration  and  slight  dyspnoea; 
whilst  in  others  it  is  dry  and  spasmodic,  and  is  accompanied  by 
marked  asthmatic  symptoms,  with  great  dyspnoea  and  anxiety. 
The  sputum  is  at  first  thin  and  frothy,  later  it  may  be  purulent 
In  the  declining  stage  of  the  disease  there  is  a  marked  tendency 
for  the  discharge  from  the  nostrils  to  become  puriform. 


flyiyMUiniiHiiiiw 


ANALYSIS  OF  CHART. 


127 


swollen 
enibrane 
The  eye 
initiated 
e  itching 
led  by  a 
igic  pains 
•all.     In 
ight  che- 
loped  the 
ely  closed 
arge  is  at 
nal  cases, 
mouth  is 
the  nares. 
iirning  or 
the  hard 
lUstachian 
casionally 
moderate 
ire  gener. 

r  laryngo- 
ily  resem- 
nptoms  of 
a  variable 
Sometimes 
!om  of  an 
across  the 
the  night, 
\  the  day, 
requently 
ead  above 
.  for  some 
moderate, 
dyspnoea; 
3anied  by 
1  anxiety, 
punilent. 
tendency 


In  some  instances,  after  a  long  and  violent  attack  of  sneezing, 
n  slight  fevor  is  discernible.  The  pulse  will  then  l)e  frequent 
and  full,  the  face  flushed,  ond  the  reHpiration  more  rapid.  This 
temporary  feverish  state  is  ui)t  to  end  with  a  slight  shivering, 
and  a  coUl  pers2)irati()n.  Active  exercise  produces  marked  ag- 
gravation of  oil  symptoms.  Hence  hay  fevor  patients  should 
keep  on  hand  a  generous  sui)ply  of  "  fatigue  material." 

After  these  symptoms  have  prevailed  with'  greater  or  lesser 
intensity  for  three,  four  or  six  weeks,  they  begin  to  decline,  and 
the  patient  enters  convalescence.  The  recovery  ic*  usually  rapid. 
The  asthma  departs  suddenly,  often  in  a  single  night,  and  the 
catarrhal  symptoms  vanish  within  two  or  three  da^s.  Frequent- 
ly the  attacks  are  prolonged  by  renewed  exposure  to  the  in- 
fluence of  pollen. 

ANALYSIS  OF  CHART. 

The  Schnelderlan  Membrane.— In  the  earlier  years  of  the 
disease,  the  action  of  the  pollen  is  most  marked  in  the  nasal  pas- 
sages. In  the  first  stages  of  the  disorder  the  fits  of  sneezing 
are  not  very  long  nor  very  severe,  but  later  on  they  become  so 
violent  that  for  the  time  being  the  patient  loses  all  self-controL 
He  may  sneeze  twenty  or  thirty  times  in  succession.  Occasion- 
ally a  profuse  cold  sweat  will  break  out  at  the  termination  of 
each  sneezing  attack.  The  frequency  of  the  sneezing  paroxysms^ 
and  the  profuseness  of  the  discharge  of  thin  wateiy  serum  de- 
pend largely  though  not  entirely,  upon  the  quantity  of  pollen 
inhaled.  After  a  time  the  alse  nasi,  as  well  as  the  mucous  mem- 
brane lining  the  nasal  passages,  become  inflamed  and  tender. 
As  the  disease  progresses  the  discharge  from  the  nostrils  tends 
to  become  inspissated  and  puriform,  especially  early  in  the 
morning. 

The  Eyes. — In  most  cases  the  irritation  of  the  eyes  follows 
ihat  of  the  nasal  passages,  but  if  the  wind  is  moderately  strong, 
and  in  consequence  thereof  an  extra  quantity  of  pollen  is 
brought  into  contact  with  the  conjunctiva,  it  may  appear  earlier 
than  the  nasal  symptoms.  The  first  symptom  is  usually  a  troub- 
lesome itching.  The  swelling  and  occlusion  of  the  lachrymal 
canals  and  nasal  ducts,  is  caused  in  part  by  the  irritation  of  the 
pollen  which  passes  down  the  duct  from  the  eyeball,  and  in  part 
by  that  which  is  deposited  in  the  nostril  during  respiration.  The 


lis 


LECTURES  ON   FEVERS. 

CHART  \II.— Hay  Feter. 


Ettnloirr: 


Time  of  H|>- 
pcariinno: 


Tho  poUuii  of  i)lunt»  nn<l  ifruKBcs. 


From  July  to  Heptciiibcr. 


CATAHitiiAf.  Form. 


StHKL-: 


Diiriitloii: 


Nose: 


SUiKO  of  ilovclop- 
inont. 


1  hour  to  4H  hours. 


Ituhinir. 

Hnccztng  In  day-tlmo. 

Watery  dlBcharifo, 


Eyo«: 


PnroxydiuBl  etHRe. 


3  to  4  wockB. 


8w«lliii»r  of  mucous  inein. 
Sni-f/luK.  <luy  iind  ulKht. 
DlwohiirKc,  wntery  &  thin, 
or  el8o  Infiptmatcu  or 
ritin 


piirlftirm. 


Itching.    Lachryinatlon 
Itchinifand         l  ,        i 


HtuKc  of  <sinvalf»- 
(«nw. 


12  houv«  to  33  hours. 


r>l8obarirc>  nt  times 
purlform. 


Lnchrymatlon. 


Mouth  and 
fnucps: 


Bars: 


Skin: 


Nouralirlc  pains 
rEilomnof  lids.  Chomosls. 


Itcblntr. 


Itching. 


Itching  and  slight  burn'g 


CEdema  of  lids  and 
Chemosls, 


Slight  dullness  of  hearing. 


At  times  a  papular  eruption  Is  present. 


Asthmatic  Fobm. 


Stage: 


Stage  of  develop- 
ment. 


Duration: 


Nose,  eyes, 

mouth 
and  fauces: 


Larynx  and 
trachea: 


Bronchi. 


1  hour  to  48  hours. 


Paroxysmal  stage. 


3  to  4  weeks. 


Stage  of  eonvaicB- 
cence. 


1  to  3  days. 


Symptoms  same  as  In  the  catarrhal  form. 


DUBoulty  of 
breathing. 


Sputum : 


Ears: 


Head: 


Slight  hoarseness. 


Wheezing.  Rales. 

Cough,  moderate  or 

severe. 

Dyspnoea. 


Slight  obstruction 
of  breathing. 


Thin,  frothy,  and  containing  granules. 


Slight  deafness. 


Tinnitus  aurium. 


Feeling  as  of  ubiind  around  the  head  above  the  eyes. 


DIFFEnENTIAL  DIAONORlfl. 


199 


itcliing  nml  burning  in  the  eyes  cause  a  constant  denire  on  the 
l)art  of  the  patient  to  rub  tliein.  ChonioHis  is  only  pHKhiceil 
when  there  is  n  maximum  quantity  of  pollen  in  the  air,  or  when 
the  patient  is  very  sensitive  to  its  action.  Photophobia  is  occa- 
sionally added  to  the  discomfort  of  the  temporary  invalid.  Tlie 
discharges  from  the  eye  are  at  lirHt  thin  and  watery,  later  they 
become  inspissated.  In  ordinary  hay-fever  attacks,  the  mischief 
does  not  extend  beyond  the  sub-conjnnctival  cellular  tissue. 

The  Month  and  Fances. — The  itching  sensations  in  the  mouth 
and  fauces  usually  follow  those  of  the  eyes  and  nasal  passages. 
They  ore  seldom  very  strongly  marked,  and  deglutition  is  rarely 
interfered  with.  At  times  there  is  a  sense  of  dryness  and  ob- 
struction in  the  throat  on  awaking  in  the  morning. 

The  Respiratory  Tract.— Chest  symptoms  appear  only  in 
the  asthmatic  variety.  The  first  asthmatic  attack  usually  comes 
on  in  the  day-time,  after  the  coryza  and  lachrymation  have  be- 
come well-marked.  And  when  asthma  once  appears  it  is  apt  to 
continue  with  more  or  less  severity  during  the  whole  of  the  hay 
season.  In  some  cases  the  dyspnoea  becomes  so  urgent  that  the 
patient  is  unable  to  lie  down.  A  scanty  expectoration  is  usually 
accomponied  by  more  dyspnoeo  than  a  copious  one.  The  dyspnoeA 
is  due  to  the  tumefaction  of  the  bronchial  mucous  membrane,  and 
the  consequent  interference  with  the  free  transmission  of  air, 
which  causes  imperfect  oxygenation  of  the  blood.  Emphysema 
of  the  lungs,  which  is  a  common  sequel  of  ordinary  asthma  is 
rarely,  if  ever,  found  to  follow  hay  asthma. 

Differential  Diagnosis. — From  ordinary  sporadic  catarrhs, 
the  catarrhal  variety  of  hay  fever  may  be  distinguished  by  its 
returning  annually  at  the  regular  season,  and  by  the  attacks  be- 
ing more  violent  during  a  residence  in  the  vicinity  of  fields  of 
flowering  grasses  and  cereals.  Flakes  of  epithelium  which  are 
frequently  found  in  the  effused  fluid  in  severe  attacks  of  com- 
mon coryza,  are  seldom  if  ever  found  in  hay  fever. 

From  common  asthma  the  asthmatic  variety  may  be  easily 
differentiated.  The  first  attack  of  the  season  of  hay  asthma  ap- 
pears in  the  day-time,  after  exposure  to  the  influence  of  pollen. 
The  first  attack  of  ordinary  asthma  comes  on  at  night,  and  fre- 
quently after  a  dyspeptic  siege.  A  primary  attack  of  ordinary 
asthma  generally  comes  on  in-doors,  that  of  hay  asthma  often 


-jji- 


130 


LECTURES  ON  FF.VEnS. 


coraeH  on  in  tlio  op^n  nir.  Th«  imroxysms  of  ordinary  nHthma 
nro  interuiittent  in  rlmrRoter,  while  tli.mo  of  hay  asthmft  nre  npt 
to  be  remittent.  The  coryzii  of  comnum  iiHthnin  ib  never  m  se- 
vero  ftB  that  of  hay  asthma.  Hay  asthma  is  a  diseaHe  of  the  sura- 
mor  months,  while  common  asthma  is  most  prevalent  during  the 
winter  seiiscm. 

Proj?iiOHlH.-The  prognosis  is  alwoys  favorable,  though  the 
diseose  tends  to  return  in  succeeding  years. 

Treatment.— PuoPHYLAXiH.  -  The  preventive  treatment  con- 
gists  mainly  in  the  removal  of  the  patient  beyond  the  reach  of 
pollen.  High  altitudes  and  the  oi)en  ocean  are  most  free  from 
it  Hence  a  residence  at  such  places  as  Deer  Park,  or  Jefferson, 
or  Paul  Sinith's  in  the  Adirondacks,  or  a  sea  voyoge  is  an  un- 
f oiling  remedy.  Many  would-lie  victims  escape  by  a  timely  re- 
moval to  the  sea-coast  Such  patients  are  quite  comfortable  and 
enjoy  immunity  from  the  attacks,  as  long  as  the  sea  breeze  blows, 
but  are  more  or  less  affected  as  soon  as  a  land  breeze  appears. 

Snlphui;  if  taken  before  the  hay  season  sets  in,  will  to  a  limited 
extent  modify  the  attacks,  but  the  Arsniicum  iodide  is  our  best 
prophylactic  remedy.  Dr.  Sebastian,  of  Texas,  has  experienced 
.good  results  from  the  wearing  of  a  thick  veil  during  the  hay 
fever  season.  In  men,  the  respirator,  alluded  to  in  the  lectures 
on  malaria,  might  be  worn  instead  of  the  veil. 

The  following  localities  and  places  of  escape  from  the  domain 
of  pollen,  are  mentioned  by  Dr.  Morril  Wyman  :  The  Glen, 
Gorham,  Kandolph,  Jefferson,  Whitefield,  Bethlehem  village, 
the  White  Mountain  Notch,  and  the  Twin  Mountain  House,  in 
New  Hampshire;  Mount  Mansfield,  in  Vermont;  the  Adiron- 
dacks;  the  Island  of  Mackinaw;  the  Lake  Superior  region;  the 
Allegheny  Mountains  at  Oakland,  and  the  Iron  Mountain.  A 
certain  immunity  is  experienced  at  Fire  Island,  off  the  coast  of 
Long  Island,  and  at  B<    '^h  Haven  on  the  Jersey  coast. 

From  this  locality  ( v  •  cago),  patients  frequently  go  to  places 
in  Northern  Michigan,  /isconsin,  or  Minnesota,  during  the  hay 
fever  season.  English  physicians  often  send  their  patients  to 
the  Highlands  in  Scotland,  or  to  the  mountainous  districts  in 
Wales. 

Palliatire  Treatment.— Nasal  douches,  or  spray  inhalations 
of  a  solution  of  glyceroborate  of  calcium,  dry  inhalations  of  an 


LEADINa  INDICATIONS. 


in 


iry  nHthma 
ma  are  apt 
ever  as  8e« 
f  the  HUin- 
iluriug  the 

hough  the 

tment  con- 
iio  reach  of 
t  free  from 
r  Jefferson, 
le  la  an  un- 
\  timely  re- 
'ortable  and 
reeze  blows, 
I  appears, 
to  a  limited 
'•  is  our  best 
experienced 
ing  the  hay 
the  lectures 

the  domain 
The  Olen, 
lem  village, 
in  House,  in 
the  Adiron- 
region;  the 
>untain.  A 
the  coast  of 
st 

go  to  places 
ring  the  hay 
:  patients  to 
i  districts  in 


r  inhalations 
ations  of  an 


iodine  and  ether  solution,  or  insufiliitions  of  Mercurius  corn, 
1st  cont.  trit.,  or  Argentuni  nitricum^  1st  dec.  trit.,  may  prove 
highly  serviceable  duriufr  the  attack.  A  weak  galvanic  current 
will  greatly  relievo  th«>  fi\  lal  headache.  The  irritation  of  the 
eyes  and  face  may  be  nll/i\<'d  by  bathing  the  parts  several  times 
per  day,  in  hot  and  cold  water,  alternately.  Voluntary  preven- 
tion of  sneezing  will  greatly  benefit  mild  cases.  Pressing  firmly 
on  the  upper  lip,  when  the  inclination  is  felt,  will  frequently  ar- 
rest a  sneezing  paroxysm.  Arseniale  of  Quinine  and  Turkish 
baths  are  occasionally  of  service  for  the  prostration. 

Leading  Indications. — Change  of  climate  is  the  most  effect- 
ive remedy.  Patients  unable  to  go  away  during  the  hay  fever 
reason,  may  however  be  greatly  benefited,  and  at  times  cured, 
by  internal  treatment. 

Aconite. — In  plethoric,  active  individuals,  and  when  there  is 
febrile  disturbance,  photophobia,  and  a  feeling  as  of  sand  in 
the  eyes.  Violent  sneezing  with  slight  discharge  of  blood  from 
nose  and  larynx.  Loud,  dry,  hard  cough,  before  or  after  sneezing. 
Numbness  in  the  back  part  of  the  throat.  After  mental  excite- 
ment. 

Allium  eepa. — Burning,  acrid  discharge,  with  violent  laryn- 
geal cough.  Smarting  of  the  eyes  with  violent  sneezing.  Must 
take  a  long  breath,  and  then  sneeze  accordingly.  Worse  in  the 
evening  and  in  a  warm  room.  Symptoms  begin  on  the  left  side 
and  travel  to  the  right 

Ammoninm  mur. — Burning  in  the  eyes,  and  lachrymation  at 
night.  Rawness  and  soreness  in  the  fauces.  Is  obliged  to  clear 
the  throat  frequently.  Burning  in  small  spots  in  the  chesi  Itch- 
ing in  the  larynx.    Dyspnoea  on  moving  and  when  lying. 

Aralia  racemosa. — Smarting  soreness  of  posterior  nares  and 
«l8B  nasi.  Frequent  sneezing.  Warm  salty  taste  in  the  mouth. 
Dry,  wheezing  respiration,  with  rapidly  increasing  dyspnoea. 
Suffocative  feeling  on  lying  down.  Loud  whistling,  worse  during 
inspiration.  Excessive  sensitiveness  to  slight  changes  of  tem- 
perature. 

Arsenicum  alb. — Is  the  best  remedy  for  a  watery,  acrid,  ex- 
coriating discharge,  with  thirst,  burning  sensations  about  the 
nose,  eyes,  throat  and  chest.    Great  restlessness  and  anxiety,  and 


? 


»fe 


IT 


K 


132 


LECTURES  ON  FEVEBS. 


er.treme  debility.  Dyspncea,  especially  when  paroxysms  are 
worse  from  midnight  till  day-break.  Pain  extending  from  the 
small  of  the  back  to  the  thighs,  when  coughing.  Symptoms 
worse  from  the  least  bodily  exertion,  and  from  a  change  of 
weather. 

Arsenicnm  iodide. — In  individuals  of  pale,  delicate  complex- 
ion, and  when  there  is  a  tendency  to  glandular  enlargement. 
Puffiness  of  the  lids.  Burning  sensations  in  the  nostrils  and 
throat.  Discharge  irritating  and  corrosive.  Worse  in  the  morn- 
ing, or  after  meals. 

Arnm  tripli. — Sneezing,  with  acrid,  fluent  discharge;  excoria- 
tion of  nostril  and  upper  lip.  All  the  symptoms  are  worse  ai> 
night. 

Asariim. — Fluent  discharge  with  deafness.  Sensation  as  if 
the  ears  were  plugged  up  with  something. 

Badiaga. — Spasmodic  cough  with  sneezing  and  lachrymation. 
Yellow  viscid  mucus  flies  from  the  mouth  and  nostrils  during  the 
paroxysm. 

Belladonna. — In  plethoric  individuals,  and  especially  in  chil- 
dren and  females  of  an  irritable  disposition.  Dryness  of  the 
mouth  and  throat.  Oflensive  smell,  after  blowing  the  nose,  as  of 
herring-brine.  The  cough  causes  sharp  cutting  pains  in  the 
head.  The  paroxysms  occur  in  the  afternoon  and  evening,  and 
are  accompanied  by  a  sensation  as  of  dust  in  the  lungs.  All  the 
Bjnuptoms  are  aggravated  by  exposure  to  the  least  current  of  cold 
air. 

Camphor. — The  1st  attenuation  of  camphor,  if  taken  as  soon 
as  the  flrst  symptoms  appear,  will  frequently  produce  a  marked 
amelioration. 

Cyclamen. — When  there  is  a  great  deal  of  sneezing,  with  rheu- 
matic pains  in  the  ears  and  head.    Loss  of  smell. 

Enphrasia. — When  the  force  of  the  disease  is  concentrated  on 
the  eye  and  its  surroundings.  In  the  early  stages,  as  soon  as  the 
.  watery  discharge  and  sneezing  begin.  When  there  is  severe  itch- 
ing and  burning  at  the  margin  of  the  eyelids,  with  swelling  of . 
the  parts.  Dry  tickling  cough  in  the  day-time,  better  from  eat- 
ing, and  drinking  small  quantities.    After  windy  weather. 


LEADING  INDICATIONS. 


133 


paroxysms  are 
nding  from  the 
ig.  Symptoms 
m  a  change  of 

jlicate  complex- 
r  enlargement, 
he  nostrils  and 
rse  in  the  morn- 

iharge;  excoria- 
ms  are  worse  at 

Sensation  as  if 

d  lachrymation. 
strils  during  the 

specially  in  chil- 
Dryness  of  the 
Ig  the  nose,  as  of 
ng  pains  in  the 
md  evening,  and 
3  lungs.  All  the 
3t  current  of  cold 

if  taken  as  soon 
roduce  a  marked 

sezing,  with  rheu- 
11. 

s  concentrated  on 
es,  as  soon  as  the 
jre  is  severe  itch- 
with  swelling  of . 
,  better  from  eat- 
iy  weather. 


Gelsemium.— Malaise.  Mucous  discharge  from  the  nose  and 
throat.  Feverishness.  Pain  iu  the  throat  runniu(;  up  to  the  ear 
when  swallowing.  Sensation  as  of  a  stream  of  soal  ling  water 
passing  from  the  throat  up  into  the  left  nostril.  Hardness  of 
hearing.    Sighing  respiration. 

Orindelia  robusta.— In  the  asthmatic  variety.  Inhalation 
easy  but  expectoration  difficult.  Accumulation  of  tenacious  mu- 
cus in  the  small  bronchi.    Excessive  nervousness. 

Ipecacuanha. — In  the  asthmatic  form.  Long  continued,  ex- 
iaustive  fits  of  coughing,  with  suffocative  spells.  Gasps  for  air 
at  an  open  window.  Cough  causes  gagging  and  vomiting,  which 
brings  relief.     Worse  from  the  least  motion. 

Kali  bich.— Adapted  to  light-haired  individuals.  Burning 
of  mucous  membrane,  extending  from  the  throat  into  the  nostrils. 
Aching  pain  at  the  root  of  the  nose,  with  fluent,  acrid  discharge. 
Pinching  pain  across  the  bridge  of  the  nose,  relieved  by  hard 
pressure.  Hoarseness  and  oppressed  breathing.  Wheezing 
cough  with  expectoration  of  tough,  stringy  mucus.  Cough  ex- 
cited by  eating  or  drinking.  Sore,  ulcerated  spots  on  the  mucous 
membrane.  Foul  tongue.  Complete  loss  of  smell.  Has  been 
successfully  used  as  a  prophylactic. 

Kali  hyd. — Swelling  and  redness  of  the  nose,  and  oedema  of 
the  eyelids.  Burning,  corroding  discharge  from  the  nostrils. 
Painful  hammering  in  the  frontal  region.  Oppression  of  breath- 
ing with  pain  in  both  eyes.  Hoarseness.  Wheezing  and  rat- 
tling in  the  chest.  White,  frothy  expectoration.  Choking  sen- 
sation on  awaking. 

Lachesis. — Excessive  sneezing,  with  copious  discharge  of 
watery  mucus.  Swelling'  and  soreness  of  the  nares  and  lips. 
Feeling  of  constriction  i.  i  the  throat  and  chest.  Sensitiveness 
of  the  larynx  with  a  feeling  of  suffocation  when  touched.  Op- 
pressive pain  in  the  chest,  as  if  full  of  wind.  Dyspnoea  worse 
after  sleep,  and  after  eating.  All  symptoms  are  worse  during 
the  day,  or  on  falling  asleep.  May  be  used  to  remove  excessive 
susceptibility. 

Mercurius.— Frequent  sneezing,  with  swelling,  redness,  and 
soreness  of  the  nose.  Acrid  excoriating  discharge.  Mucus  has 
iin  unpleasant  odor.  Inclinatioi:  to  vomit  during  coughing.  Vio- 
lent night  cough.    Pain  in  the  limbs. 


piPHswiwflWw.'.ajiijwiuiwwwMfm 


If. 


134 


LECTUBE8  ON  FEVERS. 


Nitric  acid.— Sticking  sensation  behind  the  sternum,  as  from 
splinters.  Malar  bones  are  sore.  Useful  in  the  latter  stages 
when  the  discharge  from  the  nostrils  is  thick  and  puriform. 

Nux  vom.— Feeling  of  dryness  in  the  posterior  nares.    The 

nose  is  obstruc  ;d  in  the  day-time,  but  discharges  in  the  evening. 

Opium.— When  the  asthmatic  attacks  come  on  during  sleep^ 

and  are  n,.t  to  be  followed  by  violent  fits  of  dry,  racking  cough, 

relieved  by  drinking. 

Pulsatilla.-  -Then  the  discharge  has  considerable  consistence 
and  there  are  h  Itornate  stoppage  and  discharge.  The  discharge  is 
more  copious  in  the  open  air.  In  hysterical  individuals,  or  when 
accompanied  by  deranged  menstruation.  Sudden  prostration 
with  palpitation  of  the  heart.  Dizziness  on  rising  from  a  seat. 
Copious  vomiting  of  mucus.  Constant  chilliness.  Loss  of 
smell.    Aversion  to  milk  and  fat  food. 

Bumex  crispus.— Sore  feeling  in  the  eyes.  Violent  and 
rapid  sneezing.  Fluent  discharge  with  pamful  irritation  in  the 
nostrils.    Dryness  in  the  posterior  nares. 

Sabadilla.— Violent  sneezing.  Copious  watery  discharge  from 
the  nose  and  eyes.  Severe  frontal  pain.  Redness  of  the  eyelids. 
Lachrymation  in  the  open  air,  and  when  looking  at  a  bright 
light.  Dryness  of  the  mouth,  without  thirst.  Muffled  cough, 
worse  on  lying  down.  Chilliness  with  heat  of  the  face.  Pain- 
ful lameness  in  the  knee  joints.  Is  highly  recommended  by  Dr. 
Bayes. 

Sanguinaria.— Frequent  sneezing,  worse  on  the  right  side, 
aggravated  by  odors.     Watery  acrid  discharge.      Smell  in  nose 
like  roasted  onion.    Severe  pain  at  the  root  of  the  nose,  and  in 
the  frontal  sinuses,  with  dry  cough,  and  pain  in  the  chest. 
Burning  dryness  of  the  mouth  and  throat,  not  relieved  by  drink, 
ing.    Pressure  and  heaviness  in  the  upper  part  of  the  chest, 
with  difficulty  of  breathing.    Soreness  and  burning  in  the  lungs. 
Wheezing,  whistling  cough,  and  finally  diarrhea  which  relieves 
the  cough.    Cough  worse  at  night.    Passage  of  flatus  with  the 
cough.    Bad  smelling  sputa.     Circumscribed  redness  of  the 
cheeks. 

Sticca  pul— Incessant  sneezing,  with  burning  in  the  eyes. 
Splitttng  frontal  headache  with  a  feeling  o^  fullness  at  the  root 


''r.->i-r\yM*::-'misim 


atsff 


LEADING   INDICATIONS. 


135 


.m,  as  from 
itter  stages 
riform. 

lares.  The 
he  evening. 

iiring  sleep^ 
king  cough, 

consistence 
discharge  is 
lis,  or  when 
prostration 
from  a  seat. 
3.     Loss  of 

Violent  and 
iation  in  the 

^charge  from 
E  the  eyelids, 
at  a  bright 
uffled  cough, 
face.  Pain- 
ended  by  Dr. 

e  right  side, 
Smell  in  nose 
)  nose,  and  in 
,n  the  chest, 
ved  by  drink- 
of  the  chest, 
;  in  the  lungs, 
rhich  relieves 
latus  with  the 
dnesB  of  the 


of  the  nose.  Excessive  dryness  of  the  nasal  mucous  membrane. 
Dryness  of  the  throat,  worse  at  nighi  The  secretions  dry  rap- 
idly, forming  scabs  difficult  to  dislodge.  Tickling  in  the  bronchi 
and  larynx.     Incessant,  racking  cough,  provoked  by  inspiration. 

Sulphur.— Sneezing  on  first  aAvaking  in  the  morning  or  on 
lying  down  in  the  evening.  Profuse  perspiration  after  sneezing 
or  coughing.  Continued  oppression  of  breathing  between  the 
paroxysms.  Soreness  and  ulceration  of  the  nostrils.  Rough- 
ness and  dryness  of  the  throat.  Burning  sensation  in  the 
trachea.    Expectoration  of  a  tenacious  bronchial  mucus. 

Tartar  emet. — Great  rattling  of  mucus,  with  oppressed 
breatliing.  Stoppage  of  the  nose,  alternating  with  fluid  dis- 
charge. Epistaxis  followed  by  fluid  discharge  with  sneezing. 
Loss  of  taste  and  smell.  Bheumatic  aching  in  the  muscles  and 
joints. 

Ambrosia  art.  has  been  used  with  good  success  in  varied 
types  of  hay  fever. 

For  additional  indications,  consult  Lecture  xvii,  on  the  treat- 
ment of  influenza. 


I 


ss6a 


LECTURE  X. 

Typhoid  Fever. 

At  my  last  lecture  1  completed  the  description  of  the  first 
class  of  fevers-the  miasmatic.  To-day  I  will  commence  the 
history  of  the  second  class— the  miasmaiic-cmtagious.  Ihe 
typical  disease  of  this  class  is  Typhoid  Fever. 

Defliiition.-It  may  be  defined  as  an  acute  endemic  fever, 
lasting  about  twenty-eight  days  or  longer,  due  to  a  morbific 
agent-supposed  to  be  a  rod-shaped  bacterium-associated  with 
certain  forms  of  decomposing  animal  matter.    It  is  character- 
ized by  a  gradual  approach,  marked  by  malaise,  anorexia,  duU 
headache,  epistaxis  and  a  bronchial  cough;  a  red  or  dry  and 
brown  tongue;  tympanites  and  abdominal  tenderness;  diarrhea 
idth  "pea-soup"  discharges;  rose-colored  spots,  after  the  sev- 
enthday,  appearing  in  successive  crops;  stupor  and  delirium; 
late  prostration  and  protracted  convalescence.     Constant  lesions 
of  the  solitary  and  agminate  glands  of  the  ileum,  with  enlarge- 
ment  of  the  spleen  and  mesenteric  glands,  are  found  upon  ex- 
amination after  death. 

Synoiiyiii8.-Nervous  fever.  Enteric  fever.  Autumnal  fever. 
Infantile  remittent  fever.  Gastric  fever.  Mucous  fever.  Bed- 
tongue  fever.  Endemic  fever.  Pythogenic  fever.  Abdomi- 
nal typhus. 

History  .-According  to  traditions  typhoid  fever  has  prevailed 

from  earliest  times.    Hippocrates  is  credited  as  having  narrated 

itc  symptoms  in  the  first  and  third  books  of  the  Epidemics,  and 

Gplen  described  it  under  the  name  of  hemitritmis.    During  the 

136 


iw-Hti*il»iMii'**»irti''" 


ETIOLOGY. 


187 


>£  the  first 
imence  the 
iotis.     The 

Bmic  fever, 
a  morbific 
elated  with 
I  character- 
arexia,  dull 
or  dry  and 
is;  diarrhea 
er  the  sev- 
d  delirium; 
itant  lesions 
ith  enlarge- 
nd  upon  ex- 

imnal  fever, 
'ever.  Red- 
r.    Abdomi- 

las  prevailed 

ing  narrated 

.demies,  and 

During  the 


17th  century  it  prevailed  in  Europe  and  was  described  as  the 
febvis  semitertinna.  Strother,  Huxham,  Manningham,  De-Haen 
and  StoU  outlined  it  in  the  eighteenth  century.  Petit  and  Serres 
of  France,  about  the  beginning  of  the  present  century,  first  dem- 
onstrated that  the  intestinal  lesions  were  limited  to  the  lower 
part  of  tlie  ileum.  Bretonneau,  in  1826,  proved  that  the  agmi- 
nate and  solitary  glands  of  the  ileum  were  always  implicated  in 
the  pathological  processes.  He  named  the  disease  dothienenierie. 
Louis  in  his  elaborate  work,  published  in  1829,  named  it  Jievre 
iijphoide.  Drs.  Gerhard  and  Pennock  of  Philadelphia,  in  1837, 
clearly  outlined  the  difierence  between  typhoid  fever  and  typhus 
fever.  From  this  time  the  doctrine  of  the  identity  of  these  two 
fevers  gradually  lost  foot-hold,  and  finally  was  completely  over- 
thrown by  the  series  of  papers  published  in  the  Medical  Times 
(1849-52),  by  Sir  William  Jenner.  At  the  present  day  the  doc- 
trine of  their  non-identity  is  generally  entertained  in  all  parts  of 
the  world. 

Geographical  Distribution.— Of  nil  the  fevers,  this  is  the 
one  most  universally  prevalent.  It  has  been  observed  in  all 
countries  and  in  every  clime,  but  prevails  to  the  greatest  extent 
in  the  temperate  zone.  It  is  endemic  in  the  British  Isles  and  in 
all  parts  of  Europe.  On  this  continent  it  is  endemic  from  Hud- 
son's Bay  to  the  Gulf  of  Mexico,  and  from  the  Atlantic  coast  to 
the  Rocky  Mountains.  It  has  been  met  with  in  India,  Egypt, 
and  Australia,  and  has  been  reported  as  extremely  common  in 
Brazil  and  Peru. 

Etiology. — The  causes  of  this  fever  may,  for  convenience  of 
study^be  arranged  under  the  two  familiar  heads,  j)redispoaing 
and  exciting. 

1.  The  predisposing  causes. — Climate,  indirectly,  exerts  con- 
siderable influence  in  the  development  of  typhoid  fever.  For 
while  the  disease  is  met  with  in  all  countries  it  is  especially  prev- 
alent in  the  northern  temperate  zone.  It  frequently  prevails  in 
the  same  locality,  year  after  year,  when  the  surrounding  condi- 
tions are  favorable.  As  regards  the  season  of  the  year,  it  shows 
a  decided  predilection  for  the  autumn;  hence  the  name.  Autum- 
nal fever.  It  increases  from  July  to  November,  and  then  gradu- 
ally declines,  and  becomes  less  frequent  from  February  to  April. 
The  intensity  of  the  disease  is  generally  greater  the  later  it  be- 


J..i».»IMMI»|iLMM^l«UI'«»«IIIWMIWW'«Bmill—— g 


188 


LECTURES  ON  FEVEK8. 


gins.  It  is  nlways  more  prevalent  in  the  country  nfter  hot  and 
dry  summers,  than  after  cold  and  wet  ones.  Buchanan  and 
Liebermeister  have  shown  that  the  prevalence  of  typhoid  fever 
is  somewhat  dependent  upon  changes  in  the  height  of  the  deepei* 
springs  of  water,  and  that  in  localities  where  the  disease  is  en- 
demic, and  the  specific  cause  is  in  the  earth  or  percolates  from 
privy-vaults  into  the  earth,  the  lower  the  water-level,  the  more 
abundant  is  the  fever  poison. 

A  decided  predisposing  cause  pertains  to  age.  It  is  i)re-emi- 
nently  a  disease  of  early  adult  life,  and  occurs  most  frequently 
between  the  ages  of  15  and  30.  It  is  rarely  met  with  at  either 
extreme  of  life.  It  attacks  by  preference  the  strong  ond  the 
healthy,  and  lurks  alike  in  the  palaces  of  the  rich  and  the  hovels 
of  the  poor. 

Frequently  individual  idiosyncrasies  exist,  which  seem  to  pre- 
dispose to  its  attacks.  Some  contract  the  disease  on  the  slightest 
exposure  to  the  influence  of  the  morbific  agent,  while  others 
escape  even  after  frequent  and  prolonged  exposures.  In  all, 
the  great  predisposing  cause  is  the  special  susceptibility  of 
Peyer's  patches  to  the  influence  of  the  germ. 

Habitual  exposure  to  the  poison  in  those  not  otherwise  predis- 
posed, confers  a  certain  immunity  from  the  disease.  So  does 
a  previous  attack  of  the  fever,  for,  apart  from  relapses,  it 
seldom  occurs  a  second  time  in  the  same  individual.  And  clini- 
cal experience  further  demonstrates,  that  pregnant,  parturient 
and  nursing  women,  are  rarely  affected. 

2.  Tlie  exciting  causes. — The  exciting  causes  of  typhoid  fever 
cannot  as  yet  be  definitely  outlined.  We  presume  it  to  be  an 
organized  germ,  and  to-day  know  its  nature  only  by  its  •fleets. 
Professor  Klebs,  of  Prague,  believes  that  he  has  discovered  the 
specific  poison,  and  describes  it  as  a  rod-shaped  bacterium  about 
.004  inch  long.  He  affirms  that  numbers  of  these  micro-organ- 
isms have  been  constrontly  observed  in  \'ho3e  organs  which  are 
most  afiected  by  the  disease,  and  that  thejr  have  been  found  only 
in  connection  with  typhoid  fever.  Letzerich  announces  that  he 
has  transmitted  typhoid  fever  from  man  to  rabbits  by  introduc- 
ing, per  OS  as  well  as  hypodermatically,  inferior  organisms  sus- 
pended in  distilled  water,  and  obtained  by  repeated  washings  of 
the  dejections  of  typhoid  fever  patients.  Other  experimenters, 
to  a  limited  extent,  corroborate  these  statements,  and  further  re- 


I  MiiiMftiiiirmMiHun 


ETIOLOGY. 


139 


tier  hot  and 
chanan  and 
phoid  fever 
i  the  deepp  i' 
isease  is  on- 
M>late8  from 
el,  the  more 

t  is  pre-emi- 
t  frequently 
ith  at  either 
3ng  and  the 
id  the  hovels 

seem  to  pre- 
the  slightest 
^hile  others 
res.  In  all, 
sptibility  of 

rwise  predis- 

je.    So  does 

relapses,  it 

And  clini- 

t,  parturient 

^hoid  fever 
)  it  to  be  an 
y  its  0ffects. 
scovered  the 
;erium  about 
micro-organ- 
is  which  are 
n  found  only 
ncesthat  he 
by  introduc- 
ganisms  sus- 
washings  of 
perimenters, 
d  further  re- 


searches may,  at  a  not  far  distant  day,  succeed  in  establishing 
the  causal  relation  between  these  microbes  and  typhoid  fever. 
For  the  present,  however,  the  morbific  agent  is  to  us  an  unknown 
quantity,  and  we  must  content  ourselves  with  simply  understand- 
ing its  properties. 

As  we  analyze  the  peculiarities  of  the  typhoid  poison,  and 

the  course  of  the  disease,  the  following  facts  are  demonstrable: 

1.  Typhoid  fever  never  occurs  spontaneously,  btit  is  always 

due  to  a  disease  germ,  originating  from  some  previous  case  of 

typhoid  fever. 

This  vieAV  was  first  promulgated  by  von  Gietl,  of  Munich,  and 
was  afterwards  ably  advocated  by  Dr.  Budd,  of  England.  And 
it  is  now  generally  recognized  that  when  the  disease  appears  in 
a  locality,  its  development  is  preceded  by  the  introduction  of  the 
specific  typhoid  poison,  which  has  been  reproduced  in  connec- 
tion with  decomposing  organic  matter — in  most  cases  human  ex- 
crement. 

Neither  sewer  gas  nor  the  effluvia  from  privy  vaults  are  capa> 
ble  of  generating  the  disease.  Filth  does  not  create  it,  nor  can 
the  decomposition  of  organic  and  excrementitious  substances^ 
alone  produce  it.  It  is  necessary  that  the  specific  typhoid  poi- 
son be  incorporated  in  the  decomposing  masses,  and  when  this  ia 
done  the  latter  may  become  a  germ  center.  Soil  pipes  and  sew- 
erage may  be  defective  for  a  long  time,  animal  and  vegetable 
decomposition  may  be  constantly  taking  place,  and  yet  no  case 
of  typhoid  fever  occur,  until  some  individual  having  the  disease 
comes  within  the  district,  or  some  substance  containing  the 
typhoid  poison  is  brought  within  the  boundaries  favorable  to  ita 
multiplication  and  growth. 

The  apparently  autocthonous  or  spontaneous  cases  of  the 
fever  may  be  easily  accounted  for  by  remembering  that  mild  or 
walking  cas^s  of  typhoid,  not  recognized  as  such,  or  a  case  of 
simple  intestinal  catorrh  due  to  the  influence  of  the  typhoid 
morbific  agent,  may  import  the  disease  germs  into  a  hitherto 
non-infected  locality.  And  again  it  is  possible  for  the  germ  to 
be  transported  from  an  infected  to  a  non-infected  locality  in  the 
bed-linen,  clothing  or  other  articles  soiled  by  the  dejections  of 
patients,  which  may  thus  act  as  fomites.  For  already  it  is  a  dem- 
onstrated fact  that  the  changes  which  take  place  in  the  stools 
of  typhoid  fever,  and  cause  the  reproduction  and  perfecting  of 


140 


LECTURES  ON  FEVERS. 


germs,  may  take  place  in  the  excrement  discharged  into  the  bed- 
linen  or  on  the  clothes  of  the  sick,  as  well  as  in  drains  and  sew- 
ers and  privy  vaulta 

In  whichever  way  it  is  introduced  into  a  locality  hitherto  free 
from  it,  the  affection  spreads  not  by  direct  contagion,  but  on  ac- 
count of  cess-pool,  privy  or  sewerage  contamination  from  the 
dejections  of  some  typhoid  patient.  Therefore  as  typhoid  fever 
is  never  contagious  from  person  to  person,  and  never  originates 
spontaneously  but  by  continuous  transmission  of  the  poison,  it 
justly  belongs  among  the  miasmatic-contagious  fevers,  in  the 
sense  in  which  they  were  defined  in  our  introfluctory  lecture. 

2.  Like  the  germs  of  other  acute  infectious  diseases  the  germ 
of  typhoid  fever  is,  after  introduction  into  the  human  organism, 
and  under  favorable  circumstances,  capable  of  indefinitely  re- 
producing itself. 

The  time  taken  to  so  reproduce  is  known  as  the  period  of  in- 
cubation. Its  length  is  somewhat  variable.  It  is  longer  when 
the  specific  poison  finds  access  to  the  system  by  the  ingesta, 
than  when  it  reaches  it  through  the  inspired  air.  Being  often 
an  nnascertainable  time,  the  period  of  invasion,  if  not  marked 
by  rigors,  is  reckoned  from  the  day  on  which  the  patient  betakes 
himself  to  the  bed.  The  prodromal  symptoms  are  usually  more 
severe  in  children  than  in  older  individuals.  The  duration  of 
this  stage  varies  according  to  the  constitutional  peculiarities  of 
the  patient.    It  ranges  from  fourteen  to  twenty-one  days. 

Frequently  the  germ  finds  access  to  a  system  which  is  to  it 
but  barren  soil.  The  surroundings  are  not  such  as  to  enable 
it  to  undergo  the  changes  and  indefinite  reproduction  necessary 
to  give  rise  to  typhoid  fever.  Acclimatization,  a  previous  attack, 
and  old  age,  may  be  mentioned  as  favorable  conditions  for  the 
non-reproduction  of  the  germ. 

3.  The  typhoid  specific  poison  passes  out  of  the  organism  with 
the  feecal  discharges,  but  is  not  capable  of  producing  typhoid 
fever  immediately,  but  must  first  undergo  certain  changes  out- 
side the  body,  in  connection  with  decaying  organic  matter. 

The  germ  of  typhoid  is  contained  solely  in  the  alvine  dejec- 
tions of  the  sick  And  yet  the  fresh  stools  cannot  communicate 
the  disease,  as  the  specific  poison  must  go  through  a  stage  of  de- 
velopment outside  of  the  body.  Hence  attendants  Tipjon  the 
sick  do  not  contract  the  disease  unless  they  are  exposed  to  the 


I 

! 


ETIOLOGY. 


141 


the  bed- 
mcl  sew- 

erto  free 
lit  on  f.c- 
rom  the 
aid  fever 
riginates 
joison,  it    • 
3,  in  the 
cture. 
the  germ 
)rganisin, 
litely  re- 
ad of  in- 
ger  when 
)  ingests, 
sing  often 
t  marked 
it  betakes 
lally  more 
iration  of 
larities  of 
lys. 

h  is  to  it 
to  enable 
necessary 
3US  attack, 
ins  for  the 

Binism  with 
ig  typhoid 
anges  out- 
atter. 

fine  dejec- 
mmunicate 
itage  of  de- 
I  nipon  the 
>8ed  to  the 


influence  of  the  decomposing  excrements.  The  patient's  gar- 
ments and  bed-linen  only  communicate  the  disease  when  they 
have  been  soiled  with  the  dejections  which  have  been  allowed  to 
remain  exposed  long  enough  to  undergo  decomposition.  The 
timeof  iunocuousnessof  the  stools  after  leaving  the  body  is  very 
short,  seldom  longer  than  twelve  hours. 

When  associated  with  decomposing  animal  ancT  especially 
fsBcal  matters,  the  germ  is  capable  of  reproducing  itself.  It  may 
be  diffused  primarily  from  individual  privy  vaults,  cesspools,  or 
dung-heaps;  and  secondarily  through  soakage,  from  individual 
contaminated  springs.  In  large  bodies  of  open  water  and  in 
running  streams  it  is  rendered  speedily  inert. 

4.  Under  favorable  circumstances,  and  in  a  soil  fitted  for  it» 
reception  and  gro\vth,  it  may  retain  its  activity  for  a. considera- 
ble length  of  time  after  it  has  passed  out  of  the  organism,  and 
is  also,  in  this  situation,  capable  of  propagating  itself  continu- 
ously. 

The  typhoid  germ  possesses  gi-eat  vitality,  and  may  retain  it 
for  a  long  time,  during  the  stage  of  development  through  which 
it  passes  outside  the  body.  And  as  Wilson  says:  It  may  be 
found  everywhere,  and  is  readily  capable  of  transportation  from 
place  to  place,  but  it  lurks  in  dark  neglected  corners  and  about 
the  foul  ways  of  men's  dwelling-places,  and  creeps  along  with 
oozing  filth,  crawling  into  wells  and  springs,  and  hiding  itself  in 
the  ground,  choosing  now  a  victim,  and  again  a  group  of  them 
but  i^ever  giving  rise  to  pandemics,  or  in  the  wider  sense,  even 
epidemics,  as  do  the  poisons  of  typhus,  cholera,  or  relapsing 
fever. 

In  cities  the  complex  system  of  continuous  drainage,  intensi- 
fied by  that  abomination,  the  ordinai-y  pan  water-closet,  is  occa- 
sionally conducive  to  local  epidemics.  But  a  case  of  fever  can- 
not even  here  possibly  infect  the  attendants  if  the  alvine  dejec- 
tions are  promptly  disinfected,  and  swept  away  into  properly 
constructed,  well-trapped  and  well-ventilated  sewers.  It  is  only 
where  the  excrement  is  improperly  disinfected,  or  thrown  into 
improperly  constructed  sewers,  that  it  becomes  a  focus  of  infec- 
tion. In  the  country  the  close  proximity  of  privy  vaults,  foul 
drains,  or  grave-yards,  to  drinking  wells,  is  a  common  promotive 
cause. 

Local  epidemics  are  most  frequently  observed  in  small  towna 


MMMWIMI 


i 


143 


LECTURES  ON  FEVEB8. 


and  villnges,  wliilo  sporadic  cnseg  are  constantly  encountered  in 
largo  cities  and  in  crowded  neighborhoods. 

5.  It  may  find  access  to  the  human  body  either  through 
drinking  woter  or  by  the  in8X)ired  oir. 

The  danger  of  infection  is  greater  from  drinking  contaminated 
water  than  ^rom  any  other  source.  But  observation  proves  that 
the  poison  in  contaminated  water  cnn  be  destroyed  by  boiling 
the  water.  Prof.  I.  Buckman  asserts  the  presence  of  a  peculiar 
*' fungoid  or  confervoid"  tprowth  in  water  contaminated  by  sew- 
erage or  otherwise,  and  productive  of  typhoid  fever. 

The  experience  of  late  years  has  shown  that  milk  and  meat 
are  each  occasionally  ]iroductive  of  outbreaks  of  this  disease. 
This  moy  be  explained  in  either  of  two  ways: 

a.  The  beeves  and  milch  cows  have  typhoid  fever,  or 

h.  The  water  in  which  the  milk-cans  are  washed,  or  with  which 
the  milk  is  dishonestly  diluted,  contains  typhoid  germa 

The  germs  may  olao  be  propagated  by  the  atmosphere,  and  in- 
fection can  be  produced  by  the  inhalation  of  the  exhalations 
from  privies  or  sewers  in  which  the  typhoid  poison  exists.  And 
whatever  its  channels  of  access  to  the  organism  it  manifests  a 
constant  predilection  for  the  lymph  follicles  of  the  ileum. 

From  this  brief  consideration  of  the  etiology  of  typhoid 
fever  we  are  led  to  the  following  conclusions: 

1.  That  it  is  unquestionably  a  germ  disease,  although  the  nat- 
ure of  the  morbific  agent  is  yet  unknown. 

2.  That  it  is  a  disease  of  early  adult  life;  occurs  independently 
of  over-crowding;  and  attacks  the  rich  as  well  as  the  poor. 

3.  That  it  is  non-contagious;  and  can  be  communicated  only 
through  the  excrements,  which  have  undergone  decomposition 
after  their  discharge. 

4  That  it  is  an  endemic  disease,  and,  unlike  typho-malarial 
fever,  prevails  to  a  greater  extent  in  the  country  than  in  cities. 

Clinical  History. — The  course  of  this  fever  may  be  divided 
into  the  following  six  artificial  periods,  each  one  of  which  may 
be  modified  by  complications  or  by  treatment:  the  prodromio 
period,  the  first,  second,  third  and  fourth  weeks,  and  the  period 
of  convalescence. 

1.  The  Prodromic  Period. — The  disease  may,  in  rare  instances, 
aei  in  abruptly  with  a  chill  followed  by  high  fever,  or  be  pre- 


U 


CLINICAL  HISTORY. 


143 


ceded  by  an  attack  reBembling  intermittent  fevor,  but  nsunlly  it 
is  insidious  in  its  approach.  In  most  inotanceg  for  several  days 
preceding  the  onset  of  tlie  fover,  the  patient  feels  weary,  dull 
and  indisposed  to  exertion.  He  complains  of  frontal  headache, 
epistaxis,  pains  in  the  limbs,  and  "  a  tired  feeling  all  over."  His 
sleep  is  broken  and  unrefreshing.  At  the  same  time  the  appe- 
tite i»  diminished,  and  the  tongue  is  swollen,  and  often  heavily^ 
coated.  Sometimes  there  are  abdominal  pains  and  diarrhea.' 
After  these  symptoms  have  continued  with  increasing  severity 
for  five  or  six  days,  the  fever  api)ears,  preceded  either  by  a  chill 
or  chilly  sensations  alternating  with  flashes  of  heat,  and  the  pa- 
tient is  compelled  to  take  to  his  bed. 

2.  The  First  Week. — The  onset  of  the  disease  dates  from  the 
first  rise  in  temperature.  In  the  first  week,  the  fever  steadily 
increases,  and  the  temperature  rise  is  gradual  and  uniform,  with 
regular  morning  and  evening  variations  (Fig.  10).  The  daily 
rise  begins  about  midday  and  attains  its  maximum  between 
eight  o'clock  in  the  morning  and  midnight.  At  this  time  the 
skin  is  usually  hot  and  dry;  occasionally  in  the  morning  it  is 
moist,  or  even  bathed  in  sweat.  Sometimes  chilly  sensations  are 
experienced  as  the  fever  increases  during  the  latter  part  of  the 
day.  The  headache  now  becomes  violent,  and  the  sleep  is  rest- 
less and  disturbed.  Between  sleeping  and  waking  there  may  be 
slight  delirium.  The  patient  feels  tired,  and  complains  of  a  feel- 
ing of  general  lameness.  There  are  thirst  and  loss  of  appetite. 
The  tongue  is  at  first  moist,  swollen,  and  covered  with  a  whitish- 
yellow  fur;  after  a  time  it  becomes  drier,  smooth,  and  red  along 
the  margins  and  tip,  and  is  no  longer  swollen.  In  the  majority 
of  cases  the  bowels  are  at  first  constipated,  but  diarrhea  appears 
sometime  during  this  period.  The  stools  are  painless,  brown, 
and  either  thick  or  watery.  Occasionally  diarrhea  continues 
from  the  prodromio  period,  while  not  infrequently  it  is  absent 
in  the  first  week.  Towards  the  close  of  the  period,  the  abdomen 
becomes  swollen,  and  is  tender  to  pressure  over  the  ileo-osecal 
region.  The  spleen  is  enlarged.  The  urine  becomes  scanty, 
dark-colored,  and  at  times  shows  faint  traces  of  albumen;  the 
urea  is  increased  and  the  chlorides  diminished  in  quantity.  Fre- 
quently mucous  rales  may  be  detected  in  the  posterior  portions 
of  the  lungs.  A  circumscribed  pink  flush,  which  deepens  to- 
wards evening,  and  resembles  the  flush  of  hectic,  appears  on  one 


144 


LECTUREH  ON   FF-VEHH. 


or  both  clipokn.    Tho  hi^^heHt  ovening  temperature  is  usually 
reacbe<i  at  tho  clo80  of  thiH  perioil. 

3.  The  Svcnnd  Week: — During  tho  second  week,  the  variations 
in  tcmi>erature  are  but  Blight,  and  the  fever  remains  at  about 
the  height  reached  at  the  end  of  the  tii-Ht  week  (Fig.  10).  The 
s'iin  iH  hot  and  dry,  the  face  Hushed  and  at  times  livid.  About 
the  tenth  day  the  headnche  disappears,  tho  patient  l)ecomes  in- 
different, apathetic  and  drowsy,  but  has  no  sound  sleep.  Hard- 
ness of  iliearing,  caused  by  n  catarrli  of  the  Eustachian  tubes,  or 
as  a  resiilt  of  tho  mental  state,  now  appears.  When  the  patient 
is  interrogated  as  to  his  condition,  he  usually  answers  that  he 
feels  well.  All  muscular  movements  are  feeble,  tremulous  and 
uncertain.  The  tongue  is  dry,  red,  fissured  and  covered  with 
Bordes.  It  is  protruded  with  difficulty,  and  when  protruded  the 
patient  fails  to  withdraw  it,  unless  directed  to  do  so.  The  pa- 
tient lies  on  the  back  with  the  eyes  half  closed.  Frequently 
there  is  subsultus  tendinum  and  carphologia.  He  mutters  in* 
coherently,  and  at  night  there  is  wandering  delirium.  Not  un- 
frequently  the  delirium  is  active,  and  patients  may  become 
maniacal  to  such  an  extent  as  to  require  physical  restraint. 
The  mind  is  often  occupied  with  whatever  matters  engaged  its 
attention  just  prior  to  the  illness.  The  urine  and  fseces  are 
often  passed  involuntarily ;  at  times  the  former  is  retained,  and 
contains  a  small  amount  of  albumen.  In  most  cases  the  abdo- 
men gradually  becomes  tympanitic,  and  there  is  tenderness  and 
gurgling,  especially  in  the  ileo-caecal  region.  The  diarrhea  in- 
creases, and  the  stools  are  of  a  yellowish-green  color,  resefhbling 
at  times  pea-soup;  hence  the  term  "  pea-soup  discharges."  The 
spleen  steadily  increases  in  size,  but  owing  to  the  tympanites, 
its  borders  can  rarely  be  defined.  An  eruption,  which  is  char- 
acteristic of  the  disease,  appears  between  the  sixth  and  twelfth 
days,  and  remains  visible  from  eight  to  fourteen  days.  It  con- 
sists of  small,  isolated,  lenticular,  light  red  spots,  which  disap- 
pear on  pressure,  and  come  out  in  successive  crops.  The  spots 
vary  in  size  from  a  point  to  a  line  and  a  half;  and  each  individ- 
ual spot  remains  visible  for  three  days,  and  then  disappears. 
They  vary  in  numbers  from  a  few  to  many  and  are  usually  most 
abundant  upon  the  chest  and  abdomen.  Two  or  three  well-de- 
fined spots  are  sufiicient  to  establish  the  existence  of  the  fever. 
The  eruption  is  generally  most  marked  in  cases  which  occur  be- 


CLINICAL  HIBTOliy. 


145 


usually 

iriationB 

nt  about 

).     The 
About 

omes  iu- 

.    Hard- 

tubes,  or 

e  patient 

9  that  he 

ilous  and 

ered  with 

ruded  the 
The  pa- 

'requently 

lutters  in- 
Not  un- 

ly  become 

,  restraint. 

ngiiged  its 
ffioces  are 
ained,  and 

I  the  abdo- 
ernesB  and 
iarrhea  in- 
rese  fabling 
;es."    The 
ympanites, 
ich  is  char- 
ind  twelfth 
B.    It  con- 
aich  disap- 
The  spots 
Ich  individ- 
iisappears. 
Lually  moat 
tee  well-de- 
the  fever. 
|h  occur  be- 


tween the  ngoH  ot  ten  and  tliirty.  Sibilant  and  Hub-oropitnnt 
rnlt'i;t  are,  ujM>n  pliysical  nxploration  of  the  chest,  found  to  Hup- 
ploiiiont  tlio  nmcourt  rnloH  of  the  first  week.  TheHe  rah's  are  in- 
tliciitive  of  an  extension  of  the  catarrhal  processes  to  the  smaller 
bronchi. 

4.  The  Third  Week. — In  the  third  week,  the  morning  romis- 
siouH  become  more  marked,  and  the  fever  changes  from  the  con- 
tinuous to  the  remittent  tonn  (Fig.  10).  This  change  is  usually 
a  gradual  oiio,  but  not  infro(piontly  it  takes  placo  suddenly,  some- 
times as  eorly  as  the  fourteenth  day,  with  a  liigh  evening  exacer- 
bation followed  by  a  decided  morning  remission.  The  severe 
symptoms  of  the  second  week,  however,  continue,  and  frequently 
increase  in  intensity.  For  it  is  not  until  the  end  of  this  period 
thnt  the  morning  remissions  l)egin  to  affect  the  general  condition 
of  the  patient.  And  it  often  happens  that  the  symptoms  which 
behmg  to  the  latter  holf  of  the  second  and  the  beginning  of  the 
third  week,  and  which  collectively  constitute  the  typhoid  utaiv, 
are  not  fully  developed  until  after  the  middle  of  this  period. 
The  strength  steadily  weakens,  and  the  patient  is,  now,  no  longei' 
able  to  raise  himself,  or  even  turn  in  bed.  The  stupor  deepens, 
and  the  fieces  and  urine  are  passed  involuntarily,  or  the  latter 
may  be  retained.  Emaciatiim  becomes  more  and  more  marked, 
and  bed-sores  are  apt  to  form  at  ]>oints  of  pressure.  Sudnmina 
frequently  appear  on  the  neck,  chest,  and  abdomen.  The  pulse 
grows  frequent  and  feeble.  It  is  during  this  period  that  most 
of  the  complications,  especially  those  of  the  respiratory  organs, 
are  developed. 

5.  The  Fourth  Week. — The  fever  is  now  decidedly  remittent, 
and  as  the  defervescence  draws  to  a  close,  becomes  distinctly  in- 
termittent (Fig.  10).  The  morning  fall  in  temperature  is  each 
day  lower,  and  the  evening  exacerbation  is  less  decided.  There 
is  a  gradual  amelioration  of  all  the  symptoms.  The  stupor  dis- 
appears and  the  patient  returns  to  consciousness.  The  tongue 
begins  to  clean,  the  thirst  lessens,  and  the  appetite  returns.  The 
tympanites  diminishes,  and  the  stools  are  less  frequent,  darker, 
and  of  greater  consistence.  The  nrine  is  increased  in  quantity 
and  lighter  in  color.  The  skin  is  ofttimes  bathed  in  sweat,  es- 
pecially during  sleep.  The  pulse  becomes  less  frequent,  and 
fuller.  And  the  spleen  returns  to  its  natural  size.  Notwith- 
standing an  amelioration  in  all  the  other  symptoms  occurs  dur- 


I 
I 
1 


14G 


LECTURES  ON  FEVERS. 


ins  this  pericKl,  the  emaciation  progresses  with  marked  um- 
fcrmitv  until  ikt  temperature  range  reaches  the  normal.  And 
frecmently,  so  gTeat  is  the  emaciation,  that  during  the  course  of 
the  disease  the  patient  loses  one-sixth  or  one-seventh  of  his  body- 

"^T^Convalcscencc-The  disappearance  of  the  fever  marks  the 
period  of  convalescence.     Frequently  in  the  early  days  of  this 
period  the  morning  temperature  becomes  sub-normal,     irom 
this  time,  the  weight  of  the  body  rapidly  increases,  the  appe- 
tite  returns,  and  the  patient  gains  strength  daily.     Eelapses 
rFic  11)  occur  in  about  three  per  cent  of  the  cases,  while    re- 
crudescences of  the  fever"  or  attacks  of  "after  fever"  areeas- 
ilv  brought  about  by  such  errors  in  diet  as  overfeeding  or  the 
too  early  indulgence  in  solid  food,  or  by  over-exertion  mentally 
or  physically.    Danger  of  perforation  of  the  intestine  from  deep 
ulceration  of  the  glands  of  Peyer,  exists  always  after  the  first 
week  until  late  in  convalescence.     And  it  is  not  an  infrequent 
occurrence  for  patients  out  of  bed  for  a  -eek  or  two,  to  die 
suddenly  from  this  cause.    Usually  convalescence  is  tedious,  and 
months  frequently  elapse  before  the  average  typhoid-fever  pa- 
tient regains  his  accuBtomed  health. 


iriiiiHnTTiMrT-T  -tT-"Ti" 


1 


h  marked  uni- 
3  normal.     And 
ig  the  course  of 
nth  of  his  body- 
fever  marks  the 
rly  days  of  this 
normal.     From 
eases,  the  appe- 
inily.     Eelapses 
jases,  while  "re- 
V  fever"  areeas- 
erfeeding  or  the 
xertion  mentally 
Bstine  from  deep 
'8  after  the  first 
ot  an  infrequent 
k  or  two,  to  die 
ce  is  tedious,  and 
typhoid-fever  pa- 


LECTURE  XL 
Typhoid  Fever  (Continued). 

In  my  last  lecture  I  described  to  you  the  prominent  symptoms 
of  a  typical  case  of  typhoid  fever.  To-day,  before  proceeding 
to  an  analytical  study  of  the  principal  symptoms  of  the  disease, 
I  would  invite  your  attention  to  two  types  of  cases  which  run 
an  irregular  course;  I  refer  to  the  mild  and  the  abortive  forma. 

1.  Mild  Typhoid  Fever.— In  mild  or  "walking  cases"  cf 
typhoid  fever,  the  onset  is  gradual,  the  symptoms  are  only  mod- 
erately severe,  and  the  fever  runs  its  regular  course,  but  is  of  low 
grade.  In  the  majority  of  these  cases  the  periods  approach  in 
orderly  succession,  but  are  shortened,  so  that  the  disease  runs 
its  course  in  from  sixteen  to  twenty  days.  Upon  the  fourth  or 
fifth  day  the  temperature  may  reach  104°  Fahr.  OccasionaUy 
the  temperature  curve  follows  that  of  a  typical  case  and  differs 
from  it  only  by  running  one  degree  lower.  Usually  the  erup- 
tion appears  early,  the  spots  are  few,  and  there  is  only  one  crop. 
The  diarrhea  is  mild  in  character;  at  times  it  is  absent;  and  oc- 
casionally it  alternates  with  constipation.  Some  cases  of  this 
type— the  so-called  "  walking  cases  "—are  so  mild  that  the  pa- 
tients are  not  at  any  time  confined  to  the  bed.  All  cases  of  ty- 
phoid fever,  however,  be  it  remembered  should  take  to  the  bed 
Tmreservedly  and  remain  there  until  convalescence  is  fully  es- 
tablished. For  no  matter  how  mild  the  attack,  the  intestinal 
changes  may  be  such,  that  slight  physical  exertion  shall  in  an 
unfortunate  moment  cause  intestinal  perforation,  the  almost 
inevitable  termination  of  which  is  death  from  peritonitis. 

2.  Abortive  Typhoid  Fevei\—Thi8  form  is  rare  in  this  country 

147 


prrr'rr-rf^r^^frT':??:!^^. 


148 


LECTURES  ON  FEVERS. 


though  not  uncommon  in  Europe.    It  m^  be  ushered  in.  either 
suddenly  without  prodromes,  or  gradually  with  all  the  symptom* 
of  a  typical  case.     The  temperature  curve  follows  the  regular 
course  during  the  first  week,  and  by  the  evening  of  the  third  or 
fourth  day  may  reach  104'^  or  105°  Fahr.    But  after  the  middle 
of  the  second  week,  the  fever  may  disappear  abruptly,  with  pro- 
fuse  sweating,  and  the  temperature  may  fall  rapidly  to  the  nor- 
mal  standard.    The  eruption,  the  diarrhea,  the  delirium  and  all 
the  urgent  symptoms  of  the  disease  may  be  present,  and  yet  be- 
fore  the  termination  of  the  second  period,  the  patient  may  have 
ftdly  convalesced.    Positive  evidence  of  the  typhoid  origin  of 
these  cases  exists  in  the  fact  that  ou  post-mortem  ^amination, 
the  characteristic  typhoid  lesions  are  found     As  Wilson  says, 
these  irregular  forms  are  analogous  to  modified  small-pox,  in 
which  we  have  the  primary  fever  well  marked,  but  m  consequence 
of  the  slighflocal  lesions  of  the  skin,  and  the  absence  of  suppu> 
ration,  there  is  no  secondary  fever.    It  is  probable  that  they  are 
to  be  explained  upon  the  same  ground,  namely,  that  while  the 
constitutional  disturbance  due  to  the  primary  action  of  the  ty- 
phoid  poison  is  very  great,  the  intestinal  lesion,  for  some  un- 
known reason-doubtless  depelident  upon  the  constitutional  pe- 
culiaritiesof  the  patient-is  moJerute,  and  the  glandular  deposit 
undergoes  resolution  without  ulceration  or  sloughing.    Dr.  Cay- 
ley  suggests  that  the  cases  of  typhoid  fever  that  are  from  time  to 
time  described  as  having  been  cut  short  by  special  remedies  or 
plans  ot  treatment,  are  really  of  this  character,  the  observer  hav- 
hig  ascribed  to  the  remedy  changes  which  are,  in  fact,  natural 
phenomena  of  particular  cases  of  the  disease. 

ANALYSIS  OF  CHART. 

The  Digestive  Tract.— At  the  outset  of  the  disease  the  tongue 

is  moist,  and  covered  with  a  thin,  whitish  or  yeUowish-white 

coat.    Towards  the  end  of  the  first  week  it  may  become  red  at 

the  tip  and  edges,  and  display  a  tendency  to  become  dry  in  the 

center.    It  may  remain  moist  and  coated  during  the  whole  course 

of  the  fever,  or  as  the  disease  passes  into  the  second  week  it  may 

become  brown,  dry  and  fissured.  At  any  period  the  coating  may 

become  flaky,  suddenly  peel  off,  and  leave  the  tongue  of  a  shiny, 

beefy  red  appearance.    Usually  towards  the  third  week  the 

tongue  is  protruded  tremblingly,  and  is  dry,  red  and  glazed,  and 

shows  a  brownish  streak  along  the  center,  or  a  triangular  brown- 


ii=^ 


__., u-,— «^ 


.i.lllHi!.."'"!' * ' "" 


in,  either 
ymptoms 
e  regular 
B  third  or 
le  middle 
with  pro- 
}  the  nor- 
tn,  and  all 
ad  yet  be- 
may  have 
origin  of 
imiuation, 
ilson  Bays, 
all-pox,  in 
nsequence 
of  suppu- 
at  they  are 
,  while  the 
I  of  the  ty- 
:  some  un- 
lUtional  pe- 
dar  deposit 
,    Dr.  Cay- 
•om  time  to 
'emedies  or 
)Berver  hav- 
act,  natural 


e  the  tongue 
owish-white 
come  red  at 
e  dry  in  the 
^hole  course 
week  it  may 
coating  may 
e  of  a  shiny, 
d  week  the 
I  glazed,  and 
gular  brown- 


OHABT. 

CHART  YIIL— Typhoid  Fever. 


149 


Character: 

Non-ContaH:lous.           A  previous  attack  affords  partial  protection. 

Incubation: 

Three  weeks.                             Prodromal  stajfc,  5  to  10  day s . 

Period. 

First  week. 

Second  week. 

Third  week. 

Fourth  week 

Tongrue . 

White  coatinir. 
Wed  edges  and  tip 

Dry,  red,  glazed 

Dry .      Sordts. 
Brownish   crusts 

Moist 
In  recovery. 

Intestinal 
Cunal: 

N'ausoa.     Green- 
ish vomltingr. 
Thin,  brown   dia- 
rrhea. 

"Pea-soup'      \   Hemorrhage       XIndlgestlon 
discharges.          \^                                \^ 

Perforation.   \ 

Tenipcrnture ; 

Hisos  2«  and  f  aiig 
1"  every  day. 
Ma.«imum  on 

even  In  fir  of   fifth 
day. 

lOB^tolOt". 

OBcillatlon. 

Falls  4<' 

between  night  and 

morninir. 

Retnins  to 
tht)  normal. 
1 

I'ulse: 

100  per  minute. 

100  to  lU 

120  to  140. 
IMorotic. 

■ 1 

Approaches 

Skin: 

Hot.    Hypemesthctic. 
"Musty  odor." 

Bed-sores. 

Furuncles. 

Eruption: 

Hose-rash  on 
seventh  day. 

Remains  from  8  to  14  days. 
Each  spot  lasts  3  days. 

Sudamina. 

Nervous  Sys- 
tem: 

Headache,    wake- 
fulness. 

Somnolence. 
Asthenic  delirium 

Delliium.  Tremu- 

lousnesB. 

Subsultus  tendln- 

um.     Deafness. 

Prostration. 

Head: 

Face  pale  or  livid. 
Checks  flushed. 

Falling  off 
of  the  hair. 

Urine: 

litminished.      Dark. 
Sp.  gr.  loeo  to  1090 

Increased. 
Light. 

Copious.  Pale. 
lOoftofwB. 

Abdomen : 

Tympanites.             Gurgling. 
Hlght  ileo-cfpcal  region  tender  after  the  Oth  day. 

Compllcatl'ns: 

Bronchial  catarrh. 

Bronchial  catarrh.         Lobular  pneumonia. 
Intestinal  penoratlon.      Parotitis. 

Peyor's  Patch- 
es; 

Catarrhal  Inflam- 
mation. 
Medullary  Infli- 
tration 

Follicles  swollen. 

Softening  and 

Necrosis. 

Ulceration 

Cicatrization. 

I 

Spleen-. 

Enlarifed. 

^    Diminished. 

Sequels: 

Debility.                  Paralysis.                  Abscesses. 

froirnosis: 

1 . 1 

Mortality,  lln  5.     Typhoid  fever  occurs  between  ages  of  18  and  35. 

miimumMnt*it»m*itn 


in 

■  j 


,MJl 


Mil 
H 


160 


LECTURES  ON  FEVERS. 


ish  patch  at  the  tip.    In  severe  cases  the  entire  mouth  and  tongue 
may  be  covered  with  brownish  incrustations.    As  convalescence 
approaches,  the  tongue  becomes  moist,  first  about  the  edges  and 
then  along  the  dorsum,  and  gradually  returns  to  its  natural  con- 
dition.   The  lips  often  crack,  and  become  covered  with  sordes, 
which  when  removed  cause    them  to  bleed.    In  rare  instances 
hemorrhage  from  the  gums  occurs.    Slight  catarrhal  inflamma- 
tion of  the  fauces  and  pharynx,  with  its  attendant  annoying  se- 
cretion is  usually  present  during  the  first  week.    Later  the  secre- 
tion ceases,  and  owing  to  changes  in  the  salivary  glands,  the 
mouth  and  throat  become  dry,  and  swallowing  is  difficult.    In 
children  difficult  deglutition  is  occasionally  due  to  pharyngeal 
hypertesthesia,  the  fluids  being  rejected  through  the  nostrils. 
Parotitis  may  appear  in  severe  cases  during  the  third  or  fourth 
week,  and  is  of  unfavorable  omen.    The  enlargement  commonly 
suppurates  and  is  then  very  often  fatal.     Thirst  is  generally 
present,  and  in  a  large  proportion  of  cases  is  excessive. 

The  appetUe  is  impaired  from  the  start,  and  as  the  tongue  be- 
comes dry  is  wholly  lost.  Nausea  and  vomiting  are  not  uncom- 
mon during  the  first  week.  Usually,  however,  they  appear  dur- 
ing the  second  week,  and  in  severe  cases  may  be  associated  with 
more  or  less  epigastric  tenderness.  The  matters  vomited  usu- 
ally consist  of  a  greenish  fluid.  When  vomiting  comes  on  after 
the  end  of  the  second  week,  either  it  is  due  to  gastric  catarrh  or 
appears  as  the  first  sign  of  peritonitis. 

Diarrhea  is  one  of  the  most  common  attendants  of  typhoid 
fever.  It  may  be  present  during  the  prodromic  period,  or  not 
appear  until  the  third  or  fourth  week.  The  second  week  is  the 
usual  time  for  its  appearance.  The  average  number  of  evacua- 
tions is  three  or  four  in  twenty-four  hours.  At  times  from 
twelve  to  fifteen  movements  may  take  place  per  day.  A  mild 
diarrhea  is  a  favorable  rather  than  an  unfavorable  symptom. 
Generally  the  urgency  of  the  diarrhea  bears  no  constant  relation 
to  the  extent  of  the  intestinal  lesions.  During  the  first  week  the 
stools  are  thin  and  brownish,  and  have  an  alkaline  reaction. 
Later  they  are  of  a  yellowish-green  color,  assume  the  peculiar 
typhoid  appearance,  and  contain  micrococci  and  other  bacterial 
forms.  From  this  time  they  are  known  as  "pea-soup  dis- 
charges." 


Ik 


ANALYSIS  OF  CHART. 


151 


ind  tongue 
valescenco 
edges  and 
itural  con- 
ith  Bordes, 
3  instances 
inflamma- 
moying  se- 
r  the  secre- 
jlands,  the 
fficult.    In 
pharyngeal 
le  nostrils, 
d  or  fourth 
;  commonly 
3  generally 

>  tongue  be- 
not  uncom- 
ippear  dur- 
)ciated  with 
amited  usu- 
aes  on  after 
B  catarrh  or 

I  of  typhoid 
jriod,  or  not 

week  is  the 
p  of  evacua- 

times  from 
ay.  A  mild 
e  symptom, 
tant  relation 
irst  week  the 
ine  reaction, 
the  peculiar 
lier  bacterial 
ea-soup  dis- 


Gurgling  and  tenderness  in  the  right  iliac  fossa,  nre  often 
elicited  on  palpation.  Spontaneous  i)nin  is  frequently  com- 
plained of.  The  abdominal  pain  and  tenderness,  which  are  gen- 
erally present  after  the  sixth  day,  are  due  to  local  morbid  pro- 
cesses, and  hence  increase  as  the  disease  progresses.  While  ex- 
amining the  abdomen  at  this  time  to  uscertnin  the  amount  of 
tenderness,  all  pressure  should  be  made  with  the  jjulm  of  tlie 
hand,  never  with  the  ends  of  the  fingers.  Usually  the  expression 
of  the  countenance  will  enable  you  to  determine  wliether  you  nro 
or  are  not  by  the  pressure,  causing  pain,  long  before  the  patient 
makes  an  audible  complaint. 

Intestinal  liemorrhage  occurs  in  about  five  per  cent  of  the  cases, 
and  varies  in  quantity  from  a  mere  trace  of  blood  to  one  or  more 
quarts.  If  the  blood  is  promptly  discharged,  it  is  of  a  bright 
red  color,  owing  to  the  alkaline  condition  of  tlie  intestinal  con- 
tents, and  is  either  syrupy  or  loosely  clotted.  If  it  be  retained 
for  some  time  in  the  intestine  (concealed  hemorrhage)  it  assumes 
a  tarry  consistency,  and  is  of  an  olive-green  or  brown  color. 
The  slight  hemorrhages  which  occur  prior  to  the  latter  part  of 
the  second  week,  arise  from  the  ruptured  capillaries  of  the  mu- 
cous membrane.  The  more  profuse  hemorrhages  of  the  third 
and  following  weeks  are  due  to  the  separation  of  sloughs,  or  to 
the  destructive  action  of  progressive  ulceration.  The  usual  time 
for  the  occurrence  of  extensive  intestinal  hemorrhages  is  in  the 
latter  part  of  the  second  and  during  the  third  week.  In  the  ma- 
jority of  instances  they  occur  in  severe  cases,  and  especially  such 
as  are  attended  by  profuse  diarrhea.  These  hemorrhages  are 
usually  announced  by  an  abrupt  but  transitory  fall  in  tempera- 
ture, and  by  the  speedily  ensuing  symptoms  of  collapse. 

Perforation  of  the  intestine  occurs  mostly  between  the  third 
and  fifth  week,  and  is  more  frequent  among  men  than  women. 
The  perforation  is  in  the  majority  of  instances  found  in  the  lower 
portion  of  the  ileum.  Usually,  it  presents  a  round  opening  in 
the  peritoneal  covering,  varying  in  size  from  a  pin's  head  to  a 
split  pea.  It  extends  inwards  in  the  shape  of  an  inverted  fun- 
nel, and  corresponds  either  to  an  ulcerated  Peyer's  patch,  or,  less 
frequently,  to  a  solitary  gland.  The  margins  of  the  opening 
usually  present  a  "punched-out"  appearance.  At  the  time  of 
the  perforation,  the  patient  frequently  experiences  a  sudden  pain, 
Hict  in  the  right  iliac  fossa  but  soon  extending  over  the  entire 


. 


HMn 


152 


LECTURES  ON  FEVERS. 


abdomen.  Following  this  a  state  of  collapse  supervenes.  The 
abdomen  becomes  rn|)idly  tympanitic,  the  temperature  falls,  tlio 
pulse  is  quick  and  feeble,  the  countenance  anxious  and  sunken. 
Nausea  and  vomiting  are  marked,  and  there  is  coldness  and 
bluenoss  of  the  extremities.  Occasionally  in  severe  cases  the 
patient  dies  during  the  collapse.  Usually,  however,  he  survives 
the  shock,  the  temperature  rises,  and  a  fatal  termination  does  not 
occur  until  the  third  or  fourth  day.  In  rare  instances  recovery 
may  take  place. 

Tympanites  is  a  very  common  symptom,  existing  to  some  ex- 
tent in  all  cases.  It  makes  its  appearance  about  the  end  of  the 
first  or  the  beginning  of  the  second  week,  and  remains  until  con- 
valescence is  fully  established.  The  distention  steadily  increases 
as  the  fever  advances,  and  attains  its  maximum  in  the  latter  half 
of  the  third  or  in  the  fourth  week.  It  is  due  partly  to  the  ex- 
cessive development  of  gas,  and  partly  to  deficient  expvdsive 
power.  After  its  appearance  a  gurgling  sound  may  be  produced 
by  pressing  firmly  over  the  right  iliac  fossa.  Tympanites  is  in 
part  a  measure  of  the  extent  of  the  intestinal  mischief,  and  is  al- 
ways an  imiH)rtant  diagnostic  sign.  And,  generally,  it  may  be 
stated,  that  in  iyphoid  fever,  no  matter  how  favorable  the  other 
symptoms  appear,  so  long  as  the  abdomen  remains  tympanitic, 
the  patient  is  in  more  or  less  danger. 

The  Spleen. — Enlargement  of  ihe  spleen,  with  tenderness,  is 
a  very  proaiinent  symptom.  It  appears  early  in  the  disease,  in- 
creases uniformly  during  the  second  week,  and  then  gradually 
diminishes.  It  is  greatest  in  individuals  under  thirty  years  of 
age,  and  at  the  height  of  the  disease  may  be  three  times  the 
natural  size  of  the  organ. 

The  Temperature. — In  well-marked  uncomplicated  cases  of 
this  disease,  the  course  of  the  fever  may  be  divided  into  four 
periods,  each  of  which  is  characterized  by  a  special  thermometric 
curve.  The  average  duration  of  each  of  these  periods  is  seven 
days.  Occasionally  the  typical  course  of  the  fever  is  disturbed, 
and  in  consequence  the  duration  of  the  periods  may  be  shortened 
to  five  days  or  lengthened  to  eight  or  nine  days. 

The  typical  thermometric  variations  of  a  severe  case  of  typhoid 
fever  are  well  outlined  in  Fig.  10,  and  those  of  a  mild  case  are 
represented  in  Fig.  11.    From  the  first  day  of  the  development 


168.  The 
falls,  the 
1  sunken. 
InesB  ami 
cases  the 
e  survives 
n  does  not 
i  recovery 

0  some  ex- 
end  of  the 
i  until  con- 
y increases 
latter  half 
r  to  the  ex- 
i  expulsive 
e  produced 
anites  is  in 
f ,  and  is  al- 
,  it  may  be 
e  the  other 
tympanitic, 

adernesB,  is 
disease,  in- 
n  gradually 
rty  years  of 
B  times  the 

ted  cases  of 
ed  into  four 
lermometric 
ods  is  seven 
IS  disturbed, 
)e  shortened 

jeof  typhoid 
lild  case  are 
development 


154 


LECTURES  ON   FEVEnR. 


of  the  fever,  and  through  the  first  period,  the  pyrogenic  course 
of  the  disense  is  rapid  and  progressive.  The  tempernture  for 
three  or  four  days  rises  about  1.8"  Fuhr.  to  2.7°  Fahr.  from  each 
morning  till  evening,  and  falls  again  from  the  evening  to  tho 
following  morning  0.9°  Fahr.  to  1.3°  Fahr.  BetAveen  ntxjn  ond 
evening  of  the  fourth  or  fifth  day,  the  maximal  height,  104°  to 
106°,  is  reached.  The  daily  rise  begins  about  noon,  and  is  com- 
pleted before  11  P.M.,  usually  between  4  and  7  P.  M.  The  fall 
occurs  between  midnight  and  10  A.  M.,  oftener  between  6  and  9 
A.  M.  Two  temperature  observations  should  be  taken  daily;  one 
about  8  A.  M.,  and  the  other  about  9  P.  M. 

In  the  second  half  of  the  first  week,  and  the  first  half  of  the 
second  week,  the  course  of  the  temperature  is  quite  uniform,  an  J 
the  fever»is  described  as  continuous.  Towards  the  close  of  the 
week,  the  evening  rise  often  fulls  a  little,  and  the  morning  re- 
missions become  a  trifle  more  marked.  All  irregularities  in  the 
second  week,  should  be  viewed  with  suspicion.  A  severe  course 
of  the  disease  may  be  predicted,  when  the  morning  temperatures 
remain  stationary  at  103°  Fahr.,  and  the  evening  ones  above 
104.9°  Fahr.,  and  when  the  temperature  does  not  moderate  be- 
fore the  twelfth  day.  Recovery  rarely  takes  place  ofter  a  morn- 
ing temperature  exceeding  104.9°  Fahr.,  or  an  evening  tempera- 
ture exceeding  107.2°  Fahr.  If  the  morning  temperature  exceeds 
105.8°  Fahr.  death  is  almost  certain. 

In  the  third  week,  the  morning  remission  becomes  marked, 
and  with  it  the  temperature  foils,  althoiigh  the  evening  exacerba- 
tions may  reach. the  same  degree  as  in  the  week  preceding.  The 
change  of  the  fever  from  the  continuous  to  the  remittent  form  is 
usually  gradual,  occasionally  it  is  sudden,  and  is  then  announced 
by  a  high  evening  temperature  followed  by  a  decided  morning 
remission.  By  the  end  of  the  third  week  the  morning  tempera- 
ture during  the  remission,  will  be  two  or  three  degrees  lower 
than  during  the  second  week.  The  surest  course  towards  con- 
valescence is  mapped  out  by  increased  morning  remissions  suc- 
ceeded by  milder  evening  exacerbations. 

In  the  fourth  week,  the  fever  changes  from  the  remittent  to 
the  intermittent  type.  The  morning  temperature  is  each  day 
lower,  and  the  evening  exacerbation  less  decided  (Fig.  11),  so 
that  frequently  by  the  end  of  the  week  the  normal  standard  is 
reached.    In  severe  cases  a  striking  rise  of  0.9°  Fahr.,  or  more. 


■.iiwiitiiiuiLii 


MMMkMil 


TEMPERATURE  CYCLE. 


155 


lie  course 
:ature  for 
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11  g  to  tho 
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The  fall 
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lose  of  the 
Qorning  re- 
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ones  above 
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tent  form  is 
in  announced 
ied  morning 
ing  tempera- 
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towards  con- 
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is  each  day 

(Fig.  11),  eo 
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150 


LECTURES  ON  FEVERS. 


I 


i!  I 


about  the  twenty-fifth  dny,  happening  in  the  middle  of  a  well- 
mnrked  remission  is  a  not  uncommon  occurrence. 

Convalescence  may  be  said  to  be  established  when  the  ther- 
mometer shows  absence  of  fever  for  two  successive  evenings. 
Frequently  during  this  period  the  temperature  falls  to  96.8° 
Fahr.  or  97. 7^  Fahr.  in  the  morninfr,  and  under  98.6°  Fahr,  in 
the  evening.  Relapses  are  to  be  dreaded  if  elevations  of  tem- 
perature above  the  normal  occur  eight  days  after  the  beginning 
of  convalescence  (Fig.  12). 

The  Pnlse  is  increased  in  frequency  in  proportion  to  the  rise 
in  temperature.  During  the  first  week  it  becomes  more  and 
more  frequent,  and  at  its  close  may  reach  100  or  110  per  minute. 
Throughout  the  second  week  it  remains  at  about  the  same  height 
In  the  third  and  fourth  weeks  it  may  either  gradually  diminish 
in  frequency  or  run  as  high  as  120  or  140.  Accidental  causes, 
such  as  simply  lifting  the  patient  in  bed,  may  increase  the  pulse 
twenty  or  thirty  beats  per  minute.  A  pulse  which,  without 
special  cause,  remains  for  five  or  six  consecutive  days  above  120 
per  minute,  is  a  bad  omen,  and  usually  indicates  the  commence- 
ment of  a  paralysis  of  the  heart. 

In  the  early  stages  the  pulse  is  full  and  frequent;  later  it  be- 
comes soft,  compressible  and  dicrotic,  and  in  the  advanced  stages 
it  may  be  small,  undulating,  irregular  or  uncountable.  After  the 
second  week,  should  it  any  time  become  irregular  and  intermit- 
ting, the  heart's  impulse  imperceptible,  and  the  first  sound  in- 
audible, a  fatal  issue  may  be  anticipated.  Marked  coldness  of 
the  hands  and  feet,  occurring  while  the  internal  temperature  is 
high,  is  an  important  sign  of  impending  danger  from  failure  of 
the  heari  Collapse  which  occurs  in  consequence  of  a  sudden 
fall  of  temperature  is  a  not  unfavorable  indication. 

The  Respirations  rise  with  the  pulse.  Frequently  there  is 
bronchitis,  with  shallow,  and  rather  rapid  breathing,  with  some 
sonorous  rales  over  the  chest  The  peculiar  character  of  these 
rales,  which  give  a  dry,  ringing  sound,  often  enables  you  to  make 
the  diagnosis  of  typhoid  fever  positive.  Lobar  pneumonia  is  a 
common  complication,  especially  in  the  last  part  of  the  second, 
and  in  the  third  week. 

Hypostasis  and  pulmonary  oedema  may  occur  any  time  after 
the  second  week,  as  a  result  of  the  enfeeblement  of  the  circula- 
tion.   Acute  miliary  tuberculosis  is  an  occasional  sequel 


11, 


riin 


mmmmm 


ANALYSIS  OP  CHAllT. 


157 


le  of  a  well- 

len  the  ther- 
ve  evenings, 
nils  to  96.8° 
1.6°  Fahr,  in 
iions  of  tem- 
lie  beginning 

an  to  tlie  rise 
B8  more  and 
0  per  minute. 
)  same  lieight. 
ally  diminisli 
dental  causes, 
sase  the  pulse 
hich,  without 
ays  above  120 
he  commence- 

it;  later  it  be- 
Ivanced  stages 
ble.    After  the 
and  intermit- 
first  sound  in- 
ed  coldness  of 
temperature  is 
from  failure  of 
ce  of  a  sudden 
n. 

luently  there  is 
ling,  with  some 
iracter  of  these 
»les  you  to  make 
pneumonia  is  a 
t  of  the  second, 

r  any  time  after 
t  of  the  circula- 
al  sequeL 


The  CtttaneoiiN  Surface. — In  severe  cases  by  the  second  week 
the  countennnco  has  a  pale,  livid,  muddy  appenrnnce,  and  circum- 
scribed roHO-colored  spots  are  formed  over  one  or  both  cheek- 
bones. Soiuotinie  between  the  seventh  and  the  fourteenth  day 
from  the  beginning  of  the  fever  (the  patient  usually  taking  to 
his  bed  on  the  fifth  day),  that  characteristic  symptom  of  typhoid 
fever — ilio  eruption — makes  its  appearance.  It  is  occasionally 
preceded  by  a  faint  scarlet  rash,  and  is  found  mostly  upon  the 
abdouen  and  lower  part  of  the  chest,  between  the  nipple  and  the 
umbilicus,  especially  on  tlie  right  hypochondrium  over  the  ar- 
ticulation of  the  cartilage  of  the  eighth  rib.  It  consists  of  small, 
slightly  elevated,  round  or  oval,  deleble,  rose-colored  spots, 
which  vary  in  diameter  from  a  point  to  a  line  and  a  half.  The 
spots  are  developed  in  successive  crops,  and  each  spot  remains 
visible  three  days.  They  resemble  flea-bites,  although  paler  in 
color.  They  disappear  upon  slight  pressure,  and  return  imme- 
diately when  the  pressure  is  removed.  They  are  usually  few 
in  number,run  their  course  without  change,  and  disappear  leav- 
ing no  trace  upon  the  skin.  They  give  no  feeling  of  hardness 
to  the  finger  passed  over  them,  and  are  not  seen  after  death. 
The  duration  of  the  eruption  is  three,  eight,  or  ten  days.  It 
disappears  before  convalescence  is  established,  but  may  re-ap- 
pear in  true  relapses.  It  is  most  marked  between  the  ages  of 
ten  and  thirty.    Jenner  found  it  present  in  148  out  of  152  cases.  |e»^ 

Late  in  the  disease,  minute  transparent  vesicles,  called  suda- 
mina,  frequently  appear  over  the  surface  of  the  body.  Boils 
and  abscesses  are  very  often  met  with.  Bed-sores,  defined  as 
gangrene  resulting  from  pressure,  frequently  form  over  the 
sacrum  and  trochanters,  and  at  times  over  the  elbows,  heels  and 
occiput.  They  prove  troublesome  and  often  serious  complica- 
tions of  typhoid  fever.  The  hair  falls  during  convalescence. 
All  through  the  disease  the  skin  emits  a  musty  odor,  which  is 
held  by  some  to  be  pathognomonic. 

Emaciation  appears  early  and  is  progressive.  So  general  is 
it  that  even  after  convalescence  is  established  a  long  time  often 
elapses  before  the  patient  regains  his  normal  healthy  appear^ 
ance.  Occasionally  after  a  severe  attack  of  the  fever,  the  system 
tmdergoes  a  change,  and  patients  who  have  heretofore  been 
lean  become  fat,  and  vice  versa. 


158 


LECTURES  OX  FEVERS. 


Thft  Vrino  is  dlrainirthod  in  quantity  during  the  first  two 
weeks  of  tlio  fever,  and  linH  n  typhoid  odor,  like  tli«  btxly.  It  ia 
th(!n  darker  in  color  and  has  a  specific  gravity  of  from  1020  to 
lOHO.  In  the  advanced  stage  ol  the  fever,  and  especially  during 
convalescence,  it  is  pale,  copiouR,  fu.-'.ming,  and  of  low  specific 
gravity.  The  amount  of  uroo  excreted  is  increased  about  one- 
fifth,  and  is  greatest  when  the  temperature  jk  highest.  The 
chlorides  are  greatly  diminished  during  the  fever,  but  re-appear 
as  convalescence  is  established.  Albumen  apjMjars  in  urine  in 
nearly  one-third  of  llie  cases.  When  present  the  amount  is 
small,  and  of  short  duration.  It  rarely  appears  earlier  than  the 
middle  of  the  third  week,  but  when  it  does  appear  it  is  apt  to  be 
associated  with  grave  cerebral  symptoms,  llenal  epithelium  and 
tul>e-casts  are  frequently  discovered  along  with  the  albumen. 
Late  in  the  disease  the  urine  often  contains  a  large  amount  of 
phosphates.  Catheterism  is  frequently  rendered  necessary,  after 
the  second  week,  on  account  of  urinary  retention.  Vesicol  ca- 
tarrh not  rarely  occurs  during  convalescence. 

Tlie  Neriious  System. — Headache  is  one  of  the  earliest  and 
most  constant  symptoms  of  typhoid  fever.  It  is  usually  de- 
scribed as  a  dull,  heavy  pain,  and  is  commonly  confined  to  the 
forehead  and  temples;  sometimes  it  extends  over  the  whole 
head.  It  is  most  severe  during  the  first  week,  and  ceases  spon- 
taneously about  the  tenth  day.  Associated  with  it,  there  are 
slight  vertigo,  intolerance  of  light,  and  pain  in  the  back  and  ex- 
tremities. 

Somnohmce  usually  appears  sometime  during  the  seoondweek. 
At  first  the  drowsiness  is  only  slight,  but  later,  especially  in 
severe  cases,  it  becomes  more  and  more  profound.  Frequently 
it  is  interrupted  by  delirium.  In  children  somnolence  is  a  fre- 
quent and  valuable  diagnostic  sign. 

At  any  time  the  occurrence  of  hysterical  manifestations  should 
render  the  prognosis  guarded  as  to  coming  nervous  symptoms. 

Delirium  is  commonly  present.  It  is  often  slight  and  may 
occur  chiefly  at  night  time,  or  between  sleeping  and  awaking. 
It  rarely  appears  before  the  middle  of  the  second  week,  though 
exce])tionally  maniacal  delirium  is  the  first  symptom  leading  to 
the  supposition  that  the  patient  is  ill.  The  characteristic  form 
of  the  delirium  is  the  "  low  muttering."    Sometimes,  however. 


.'^SSeatWMMHRSHSKM 


ANALYKIS  OF  rilAIlT. 


159 


lie  first  two 
body.     It  ia 
from  1020  to 
ciiiUy  during 
low  specific 
id  (luuut  onc- 
ligliest.    The 
but  re-ftppear 
rs  in  urine  in 
le  amount  is 
rlier  tlian  the 
it  is  apt  to  bo 
pithelium  an.l 
the  albumen, 
rge  amount  of 
ecessary,  after 
1.    Vesical  ca- 


he  earliest  and 
is  usually  de- 
confined  to  the 
)ver  the  whole 
ad  ceases  spon- 
th  it,  there  are 
lie  back  and  ex- 
he  second  week, 
er,  especially  in 
ad.    Frequently 
nolence  is  a  fre- 

Eestations  should 
ous  symptoms, 
slight  and  may 
ig  and  awaking, 
md  week,  though 
mptom  leading  to 
laracteristic  form 
aetimes,  however, 


it  ifl  pctiveand  noisy  from  the  start,  so  nn  to  rt'utlor  phywical  re- 
straint necoasnry.     The  mind  ih  dull  and  stupid. 

MiitiCiiUtr  jH'ostrafion  is  noticoublo  in  all  sovcro  pasps  from  the 
boginning  of  tlio  tover  and  increaHcs  with  itw  progrosn.  It  is 
usually  most  markod  during  the  socond  or  third  weok.  lleten- 
tiim  of  urino  and  involuntary  evacuations  from  the  bowels, 
when  occurring  early  in  cases  in  which  the  prostration  is  ex- 
treme, are  unfavorable  symptoms.  Vesical  paralysis  is  a  not 
uncommcm  sequel. 

Mnscnlar  ireniors,  esijccially  trembling  of  the  hands,  tongue, 
and  lips,  are  oftenest  mot  with  in  old  and  feeble  persons,  and  in 
thoHo  who  are  addicted  to  the  use  ot  spirits.  In  the  advanced 
stages  of  severe  cases,  subsultus  tondinum,  carphologia,  and  hic- 
cough are  obsen'ed.  General  convulsions  are  rare,  except  in 
very  young  children.  Poraplegia  occasionally  appears  either  dur- 
ing the  course  of  the  fever,  or  after  the  commencement  of  con- 
valescence. 

The  Special  Senses. — EpisUixis  is  a  common  symptom  and 
is  apt  to  occur  early  in  the  disease. 

Deafness  is  most  marked  about  the  middle  period  of  the  fever 
and  usually  affects  both  ears.  One-sided  deafness  is  generally 
caused  by  ulceration  of  the  mucous  lining  of  the  Eustachian 
tube,  or  by  suppuration  of  the  middle  ear.  In  severe  cases, 
ringing  and  humming  in  the  ears  are  complained  of  during  the 
early  days  of  the  fever.  At  the  middle  of  the  second  week,  about 
the  time  the  delirium  appears,  the  pupils  will  be  found  abnor- 
mally dilated.  In  rare  instances  paralysis  of  accommodation 
occurs  as  a  sequel. 

Hypercesthesia  of  the  surface  of  the  body  is  common  in  fe- 
males and  in  children.  It  is  most  marked  over  the  abdomen  and 
lower  extremities,  and  is  generally  associated  with  tenderness 
along  the  spine. 

Dnration. — The  average  duration  of  typhoid  fever  is  from 
three  to  four  weeks.  In  a  typical  case  the  length  of  the  stage 
of  invasion  varies  from  one  to  five  days.  The  stage  of  glandular 
enlargement  continues  until  the  twelfth  or  fourteenth  day,  and 
the  ulcerative  stage  extends  from  the  fourteenth  day  to  some- 
time between  the  twenty-first  and  twenty-eighth  days.    The 


160 


LECTUKES  ON   FEVERS. 


stage  of  convalescence  lias  an  average  length  of  from  one  to  two 
weeks.  The  period  of  greatest  danger  is  about  the  close  of  the 
third  week.  Death  seldom  occurs  earlier  than  the  fourteenth 
day. 

Belapsc!^. — A  relapse  has  been  defined  as  a  second  evolution 
of  the  ppecific  febrile  process  after  the  establishment  of  convales- 
cence, and  is  due  to  re-infection  by  the  specific  cause,  either  from 
a  new  and  second  infection  from  the  source  of  the  original  poison, 
or,  which  appears  more  probable,  from  resorption  of  the  poison 
thrown  off  in  the  faeces.  It  is  ixsually  milder  and  of  shorter  du- 
ration than  a  primary  attack.  Most  commonly  it  occurs  singly 
though  occasionally  a  second  or  even  a  third  may  take  place. 
It  may  be  ushered  in  by  chilliness  or  rigors,  or  declare  itself, 
after  a  period  of  interval  of  from  one  to  five  days,  by  a  sudden 
recurrence  of  febrile  symptoms.  The  temperature  bounds  at 
once  to  103°  Fahr.  or  104°  Fahr.  and  may  be  either  continuous 
or  attended  by  remissions  (Fig.  12),  The  eruption  reappears, 
frequently  as  early  as  the  fourth  day,  the  spleen  again  enlarges, 
the  intestinal  and  abdominal  sympt  ms  return,  and  the  majority 
of  the  characteristic  symptoms  of  the  primary  attack  are  repro- 
duced. The  fever  attains  its  maximum  about  the  evening  of  the 
fifth  day,  and  a  critical  fall  takes  place  about  the  eighth  or  ninth 
day.  On  the  tenth  day  a  decided  rise  again  occurs.  From  this 
time  the  morning  remissions  become  more  and  more  pronounced^ 
and  the  temperature  returns  in  a  zigzag  manner  to  the  normal 
degree  with  convalescence.  A  fatal  termination  is  a  rare  occur- 
rence unless  perforation  takes  place.  The  intestinal  lesions  of 
a  relapse  are  usually  less  numerous  than  in  a  primary  attack,  and 
the  ulceration  is  hi{;^her  up. 

"After  fevers"  or  "recrudescences  of  fever"  which  are  gen- 
erally dependent  upon  unhealed  ulcers,  and  arise  from  dietetic 
errors  or  over-exertion,  are  entirely  different  from  true  relapses, 
and  last  only  a  few  days. 

Morbid  Anatomy. — The  anatomical  lesions  of  typhoid  fever 
are  in  many  instances  so  peculiar  and  characteristic  that  at  an 
autopsy,  an  experienced  observei-  can,  without  previous  knowl- 
edge of  the  history  and  symp'  ^ms  of  the  case  examined,  make  a 
positive  diagnosis. 

Early  in  the  disease,  as  soon  as  the  characteristic  symptoms 


a«^a;-«BH5SBBB 


from  one  to  two 
the  close  of  the 
L  the  fovirteenth 

econcl  evolution 
lent  of  convales- 
luse,  either  from 
I  original  poison, 
an  of  the  poison 
d  of  shorter  du- 
it  occurs  singly^ 
may  take  place. 
)r  declare  itself, 
lys,  by  a  sudden 
•ature  bounds  at 
ither  continuous 
ption  reappears, 
a  again  enlarges, 
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ler  to  the  normal 
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'  which  are  gen- 
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:om  true  relapses, 

of  typhoid  fever 
eristic  that  at  an 
t  previous  knowl- 
axamined,  make  a 

teristic  symptoms 


RELArSE. 


161 


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162 


LECTURES  ON  FEVEES. 


appear,  the  blood  becomes  darker  in  color  and  gradually  loses  its 
fibrin.     Later  it  becomes  thin  and  watery,  and  the  number  of 
white  globules  is  largely  increased.     The  S2)leen  becomes  en- 
larged, softened    and    pigmented.      The    enlargement  begins 
early,  and  attains  its  acme  at  the  beginning  of  the  third  week. 
It  then  gradually  diminishes,  and  reaches  the  normal  during 
convalescence.     On  section  the  organ  is  found  to  be  of  a  brown- 
ish-red, almost  black  color.     In  the  early  stages  it  is  of  moderate 
consistence,  but  later  it  is  a  soft,  friable,  jelly-like  mass.    Near 
the  close  of  the  disease  infarctions  are  often  met  with,  and  in 
rare  instances,  spontaneous  rupture  occurs.     According  to  Ger- 
hardt,  in  cases  in  which  relapse  takes  place,  the  spleen  frequently 
remains  enlarged  during  the  apyreriai  period  between  the  pri- 
mary attack  and  the  relapse.    The   iver  is  in  most  cases  normal 
in  appearance;  occasionally  it  is  sol  oened,  and  the  cells  are  more 
or  less  granular  and  fatty.     Nodules,  consisting  of  lymphoid 
cells  are  at  times  found  along  the  course  of  the  small  veins. 
The  amount  of  bile  is  generally  diminished,  and  in  the  later 
stages  it  is  thin  and  almost  colorless. 

The  Kiihieys.— Degenerative  changes  in  the  kidneys  are  usu- 
ally associated  with  albuminuria.  When  present  they  affect 
first  the  cortical  and  later  the  medullary  portion  of  the  organ. 
Infarctions  are  sometimes  observed. 

The  heart  undergoes  parenchymatous  degeneration  in  propor- 
tion to  the  intensity  and  duration  of  the  febrile  movement.  In 
most  instances  it  becomes  soft,  flabby,  friable,  and  of  a  pale  gray 
or  "  faded-leaf"  color.  On  microscopical  examination,  the  mus- 
cular fibres  will  be  found  to  have  undergone  granular  degenera- 
tion, sometimes  to  such  an  extent  as  to  efface  the  striations. 
The  feebleness  of  the  heart's  action,  especially  in  severe  cases, 
is  always  proportionate  to  the  extent  of  this  degeneration. 

The  Lungs.— The  dependent  portions  of  the  lungs  frequently 
present  the  condition  of  hypostasis.  When  the  hypostasis  is 
complete,  the  lung  tissue  is  of  a  dark  brown  or  black  color,  and 
is  then  in  the  condition  termed  splenization.  The  bronchial 
glands  are  at  times  enlarged,  and  evidences  of  pneumonia  are 
ofttimes  present.  Pulmonary  oedema  is  frequently  observed. 
In  thd  bronchial  tubes— especially  the  larger  ones— evidences  of 
catarrhal  inflammation  are  almost  always  found.    The  larynx  is 


THE  INTESTINAL  LESIONS. 


163 


lally  loses  its 
le  number  of 

becomes  en- 
iment  begins 
e  third  week. 
)rmal  during 
e  of  a  brown- 
s  of  moderate 
',  mass.  Near 
t  with,  and  in 
»rding  to  Ger- 
!en  frequently 
tween  the  pri- 
;  cases  normal 
cells  are  more 

of  lymphoid 
9  small  veins, 
i  in  the  later 

Ineys  are  usu- 
Qt  they  a£fect 
1  of  the  organ. 

bion  in  propor- 
novement.  In 
of  a  pale  gray 
ition,  the  mus- 
ular  degenera- 
the  striations. 
n  severe  cases, 
leration. 

ings  frequently 
e  hypostasis  is 
>lack  color,  and 
The  bronchial 
pneumonia  are 
sntly  observed. 
s — evidences  of 
The  larynx  is 


frequently  the  seat  of  catarrhal  inflammation;  less  frequently  it 
is  the  seat  of  more  or  less  extensive  ulceration.  Dangerous 
hemorrhages  sometimes  take  place  from  these  well-designated 
"  typhoid  ulcers  of  the  larynx."  At  times  the  ulceration  involves 
the  epiglottis,  and  it  may  extend  upward  and  outward  io  the 
Eustachian  tube. 

The  Nervous  System. — The  brain  and  nervous  system  present 
no  known  characteristic  lesion,  although  not  infrequently  ad- 
hesions of  the  dura  mater  are  found  early  in  the  disease,  while 
cedema  of  the  pia  mater  and  brain  structure  occur  later  in  its 
■course. 

The  Muscles. — The  voluntary  muscles  may  be  the  seat  of  either 
granular  or  waxy  degeneration.  The  granular  degeneration  is 
more  frequent,  and  corresponds  to  ordinary  fatty  degeneration. 
In  waxy  degeneration  the  muscle  substance  is  converted  into  a 
waxy,  shining  mass.  Muscular  degeneration  is  most  marked  in 
the  second,  third  and  fourth  weeks.  The  abdominal  rectus,  the 
adductors  of  the  thigh,  the  pectorales,  the  diaphragm  and  the 
tongue  are  oftenest  implicated,  and  always  to  the  greatest  extent. 
The  want  of  muscular  power  which  appears  at  the  height  of  the 
disease  is  due  in  part  to  disturba'^ces  of  the  nervous  system  and 
in  part  to  muscular  changes;  but  the  excessive  loss  of  power 
during  convalescence  is  almost  entirely  due  to  these  degenera- 
tive changes  of  muscular  tissue. 

Cadaveric  rigidity  is  usually  marked,  and  long  lasting. 

Tfie  Digesiije  Tract. — Early  in  the  disease  the  salivary  glands 
and  pancreas  become  hard  and  undergo  granular  degeneration. 
At  first  they  have  the  consistence  of  cartilage  and  are  of  a  b^own- 
yellow  color.  Later  the  hardness  diminishes,  and  they  present 
a  reddish  appearance.  After  the  third  week  ulcerative  changes, 
may,  in  rare  instances,  be  found  in  the  pharynx,  and  at  the  car- 
diac extremity  of  the  oesophagus.  The  stomach  is  at  times  hy- 
persemic,  and  may  be  the  seat  of  extensive  degenerative  glandu- 
lar changes. 

The  Intestinal  Lesions. — The  principal  lesions  of  the  intestinal 
canal  involve  the  agminate  and  solitary  glands  of  the  ileum  and 
are  characteristic  of  the  disease.  The  course  of  the  pathological 
changes  which  result  in  these  lesions,  may,  for  the  convenience 
of  study,  be  divided  into  four  stages  corresponding  to  the  four 


Mlk 


tmm 


mamumtim 


164 


LECTURES  OK  FEVEBS. 


periods  o!  the  fever.  In  the  first  week— /fte  siage  of  catarrhal 
injlummaiion  and  of  medullary  wfiHratian-the  mucous  mem- 
Ijraue  especially  that  surrounding  the  Peyerian  patches,  becomes 
hyper«mic  and  swollen.  The  agminate  and  solitary  glands  be- 
come  infiltrated  with  lymphoid  cells,  and  the  patches  are  thick- 
cned  hardened  and  elevated  from  one  to  three  lines  above  the 
surrounding  membrane.  Their  surface  assumes  a  dark  reddish 
color-  forming  what  is  known  as  the  «  shaven-beard  appearance." 
These  changes  are  generally  well  marked  as  early  as  the  second 
day,  but  are  not  fully  developed  until  the  end  of  the  first  week. 

In  the  second  week— //le  stage  of  softening  and  ticcrosis— the     | 
mucous  membrane  becomes  less  hypertemic,  but  the  agminate 
und  solitary  glands  l&ecome  more  elevated  and  infiltrated.     The 
follicles  become  swollen  in  all  directions,  from  the  excessive  de- 
velopment  of  cell  elements.    As  a  result  of  the  pressure  of  these 
cells  upon  the  capillary  vessels  which  furnish  nutrition  to  the 
Glandular  structure,  the  glands  become  anaemic  and  degenerative- 
changes  occur.    In  some  of  the  glands  by  the  middle  of  the 
second  week  the  new  elements  undergo  disintegration  and  ab- 
sorption, and  the  process  ends  in  resolution.    In  others  the  m-^ 
dividual  follicles  rupture,  and  discharge  their  contents  into  the 
intestinal  canal.    More  frequently  the  swollen  patches  underga 
partial  or  complete  necrosis,  and  yellowish-brown  or  greenish 
sloughs  are  formed. 

In  the  third  week— //le  siage  of  ulceration— \he  necrotic  tissue 
separates,  leaving  a  typhoid  ulcer  with  sharp  everted  and  over- 
hanging edges.  The  size  and  depth  of  the  ulcer  correspond  to 
the  area  of  the  necrosed  tissue.  They  are  elliptical  when  an 
entire  patch  is  necrotic,  and  small  and  round  when  the  infil- 
trated solitary  glands  are  necrosed.  Usually  by  the  end  of  the 
second  week  the  sloughs  are  all  detached. 

In  the  fourth  vreek—the  stage  of  cicatrization— ihe  swollen 
edges  of  the  ulcers  gradually  subside,  and  the  surface  become* 
covered  with  granulation  tissue,  which  is  transformed  into  con- 
nective tissue,  and  ultimately  covered  with  a  layer  of  epithelium. 
The  gland  structure  is  not  regenerated.  The  resulting  scar  is 
slightly  depressed,  firm,  less  vascular  than  the  surrounding  mu- 
cous membrane,  often  more  or  less  strongly  pigmented,  and  can 
be  recognized  after  the  lapse  of  years.  It  never  causes  pucker- 
ing  and  never  gives  rise  to  diminution  in  the  calibre  of  the  m- 


DIFFERENTIAL  DIAGNOSIS. 


166 


/  catarrhut 
icous  mem- 
les,  becomes 
y  glands  be- 
es are  thick- 
es  above  the 
lark  reddish 
ippearance."^ 
s  the  second 
le  first  week. 
wcrosis — th© 
;he  agminate 
trated.     The 
excessive  de- 
isure  of  thes© 
trition  to  th© 
degenerativ© 
liddle  of  th© 
ation  and  ab- 
others  the  in- 
tents into  th© 
tches  undergo 
1  or  greenish 

aecrotic  tissu© 
ted  and  over- 
correspond  to 
itical  when  an 
hen  the  infil- 
khe  end  of  th© 

I — the  swollen 
irf  ace  becomes 
rmed  into  con- 
•  of  epithelium, 
isulting  scar  is 
irroundingmu- 
lented,  and  can 
causes  pucker- 
libreof  the  in- 


testine. Not  infrequently  the  process  of  healing  does  not  pur- 
sue this  regular  course  and  terminate  thus  favorably.  In  some 
instances  while  one  portion  of  the  ulcer  is  undergoing  cicatriza- 
tion, in  another  part  the  process  of  ulceration  may  be  extending. 
Such  long-continued  ulceration  may  prolong  convalescence,  and 
occasionally  cause  death,  either  from  exhaustion  or  by  per- 
foration. 

The  Meseniei'ic  Glands  undergo  changes  analogous  to  those 
which  take  place  in  the  intestinal  glands.  In  some  cases  all  the 
glands  are  affected,  but  usually  the  changes  are  confined  to  those 
which  correspond  to  the  diseased  portion  of  the  intestine.  They 
are  first  congested  and  then  enlarged  in  consequence  of  cellular 
hyperplasia.  The  maximum  of  enlargement  is  reached  about 
the  middle  of  the  second  or  beginning  of  the  third  week.  The 
size  attained  varies  from  that  of  a  chestnut  to  a  small  hen's  egg. 

In  the  retrogression  some  of  the  glands  simply  shrink  and  re- 
turn to  the  normal  state.  Others  undergo  softening  and  ab- 
sorption, and  leave  a  fibrous  cicatrix.  Still  others  of  large  sizd 
oare  only  incompletely  absorbed,  the  cheesy  matter  which  is  left 
undergoing,  in  process  of  time,  caicareous  degeneration.  And  a 
tew  alter  softening,  form  pseudo-abscesses,  which  may  burst 
into  the  peritoneal  cavity  and  cause  general  peritonitis. 

A  calcareous  state  of  the  mesenteric  glands,  and  pigmented 
■cicatrices  of  the  solitary  and  agminate  glands,  are  almost  posi- 
tive autopsic  symptoms  of  a  previous  severe  case  of  typhoid 
fever. 

DifTerential  Diagnosis. — The  diagnosis  of  well-marked  cases 
of  typhoid  fever  is  usually  attended  with  but  little  diflSculty. 
The  presence  of  the  febrile  movement  with  nocturnal  exacerba- 
tions and  morning  remissions,  and  the  appearance  of  frontal 
headache,  epistaxis,  bronchial  cough  with  sonorous  rales,  and 
diarrhea,  during  the  first  week,  are  suflBciently  suggestive  of  the 
disease.  The  progressive  enlargement  of  the  spleen,  the  tender- 
ness over  the  region  of  the  ileo-csecal  valve,  and  the  tympanites 
are  also  diagnostic.  Equally  characteristic  are  the  rose-colored 
•spots,  the  pea-soup  or  ochre-colored  dejections,  and  the  mutter- 
ing delirium.  In  mild,  abortive  and  irregular  types  it  is  always 
difficult  and  ofttimes  impossible  to  form  an  accurate  diagnosis. 

The  diseases  with  which  tjrphoid  fever  is  most  liable  to  be  con- 


■r 


i 


K 


pmm 


166 


LECTURES  ON  FEVERS. 


founded  are,  simple  continued  fever,  simple  remittent  fever, 
typho-malarial  fever,  typhus  fever,  relapsing  fever,  acute  tuber- 
culosi8,pneumonia,  influenza,  gastro-enteritis  and  trichiniasis. 

Simple  continued  fever  as  distinguished  from  typhoid  fever  is 
characterized  by  the  abruptness  of  the  rise  and  fall  of  tempera- 
ture, by  the  absence  of  eruption  and  of  abdominal  symptoms, 
and  by  its  short  duration. 

The  rules  for  differentiating  simple  remiUcni  fever  (p.  84) 
BJnUypho-malarial  fever  iv-  118),  from  typhoid  fever,  have  al- 
ready been  given  in  the  lectures  upon  those  diseases,  and  as 
they  are  familiar  to  you,  thoir  repetition  is  unnecessary. 

The  leading  phenomena  of  typhus  fever,  relapsing  fever,  and 
typhoid  fever,  maybe  contrasted,  for  the  purpose  of  establishing 
their  clinical  distinction,  according  to  the  following  tabular  ar- 
rangement: 


TYPHUS  FEVBB. 

An  epidemic  disease. 
Highly  contagious. 
Onset  sudden. 
Course  continuous. 

Duration  about  14  days. 


Defervescence  critical  or 
by  rapid  lysis. 


TYPHOID  FEVER. 

An  endemic  disease. 
Non-contagious. 
Onset  insidious. 
Course  continuous. 

Duration  3  to  4  weeks. 


Defervescence    by   pro- 
longed lysis. 


Relapses  rare.  Relapses  occasionally. 

Countenance,  dusky-red.      Countenance,  paleor-pnr- 

plish-red. 
Flush  circumscribed  and 
confined  to  cheeks. 


''^ 


Conjunctiva  deeply  in- 
jected ;  pupils  con- 
tracted. 


Pupils  often  dilated. 


KELAPSINO    FEVEK. 

An  epidemic  disease. 

Contagions. 

Onset  sudden. 

Course  broken  by  a  dis- 
tinct apyrexial  period. 

Duration  of  primary  par- 
oxysm 5  to  7  days ;  of 
intermission  4  to  7 
days ;  and  of  relapse  3 
days. 

Terminates  abruptly  by 
crisis. 

Relapses  constant. 
Countenance  flushed. 


ConjunctiTSB  slightly  in- 
jected ;  pupils  natural- 


ittent  fever, 
acute  tuber- 
chiniasis. 

hold  fever  ia 
of  tempera- 
1  symptoms* 

ever  (p.  84) 
)ver,  have  al- 
iases, and  as 
sary. 

iig  fever,  and 
'  establishing 
ig  tabular  ar- 


SINO    FEVKU. 

emic  disease. 

ins. 

idden. 

broken  by  a  dis- 
apyrexial  period. 

n  of  primary  par- 
1  5  to  7  days ;  of 
aission  4  to  7 
;  and  of  relapse  3 

ates  abruptly  by 

a  constant, 
nance  flushed. 


ictivjB  slightly  in- 
d ;  pupils  natural. 


DIFFERENTIAL  DIAGNOSIS. 


TYrm :s  fkveb. 
No  epistaxis. 

Skin  has  a  pungent  heat. 
Eometimes  emits  am- 
moniacal  odor. 

Mulherry-riuh.  Eruption 
deep  red,  copious,  ap- 
pears all  over  the  body. 

Appears  on    5th  or  6th 
day.  Each  spot  remains 
until  the  close  of  the 
disease. 

Temperature  rises  rapidly, 
reaches  104°  or  106°  at 
end  of  2d  day. 

Falls  rapidly  after   the 
12th  or  14th  day. 


167 


I 


Pulse,  soft,  100  to  140. 

Delirium     and     stupor, 
early  and  prominent. 


TYPHOID   KEVEB.  | 

Epistaxis  common. 

Skin  sometimes  bathed 
in  acid  perspiration. 
Musty  odor. 

'•Rose-rash."  Eruption 
light  red,  thinlyscat- 
tered,  confined  tochest 
and  abdomen. 

Appears  on  7th  to  9th 
day.  Each  spot  lasts 
3  days. 

Temperature  rises  2° 
from  morning  to  even- 
ing and  falls  1°  from 
evening  to  morning. 

Reaches  104°  on  morn- 
ing of  4th  day.  Re- 
turns gradually  to  the 
normal  standard  in  4th 
week. 

Pulse  100  to  140. 

Cerebral  symptoms  ap- 
proach gradually,  and 
last  longer. 

Abdominal     symptoms 

prominent. 
Diarrhea,ty  mpanites  and 

gurgling. 
Tenderness  in  right  iliac 

fossa. 
Emaciation  great. 

Bronchitis  and  plenritis. 

Death  rarely  within  14 
days,  usually  in  or  af- 
ter 3d  week.  Mortal- 
ity, 20  per  cent. 

Constant  lesions  of  ileum 
and  mesenteric  glands. 


KEL  .P8INO  FEVEK. 

Epistaxis  occasionally,  es- 
pecially at  crisis. 

Skin  is  hot.  Profuse 
sweat  at  the  crisis. 

No  defined  rash.  Some- 
times a  rose  eruption 
resembling  roseola. 


Temperature  rises  rap- 
idly to  104°  or  even 
109°,  within  24  hours. 

Falls  suddenly  during  the 
remission.  Rises  rapid- 
ly during  relapse  to 
106°  or  107°. 

Pulse,  small,  140  to  160, 
Mind  usually  clear. 


Pain  and  tenderness  in 

epigastrium. 
Constipation. 
Sometimes  diarrhea  at 

crisis. 

Emaciation  not  marked. 
Bronchitis  common. 

A  Mai  teimination  is 
rare. 


Lesions  not  characteristic* 


mm 


.  [ 


p 


F 


k:, 


168 


LECTURES  ON  FEVERS. 


A  variety  recognized  by  Niemeyer  as  gasiric  fever  is  occasion- 
ally mistaken  for  typhoid  fever  although  it  oftener  simulates 
typho-malarial  fever.  It  commences  with  headache,  malaise  and 
anorexia,  followed  by  a  slight  chill,  with  marked  gastric  irrita- 
bility, nausea,  vomiting  and  constipation.  There  is  marked  epi- 
gastric tenderness,  and  a  peculiar  sweetish  or  garlic-like  uilor  io 
the  hreaih,  which  is  believed  to  be  pathognomonic.  The  tem- 
perature rises  at  first  to  100°  Fahr.  but  falls  below  the  normal  as 
the  disease  advances.  The  pulse  beats  from  60  to  70  per  minute. 
This  variety  of  fever  occurs  more  in  women  than  in  men,  and 
oftener  after  the  middle  period  of  life.  It  differs  from  typhoid 
fever  in  that  it  has  neither  tympanites,  diarrhea,  delirium,  sub- 
Bultus  tendinum,  eruption,  iliac  tenderness,  nor  sordes.  Its 
mortality  is  higher  than  that  of  typhoid;  and  double  vision  or 
total  loss  of  sight  is  considered  a  grave  symptom. 

Acute  tuberculosis  is  attended  by  many  symptoms  of  typhoid 
fever.  Its  fever  rise  is,  however,  more  sudden,  for  early  in  the 
disease,  the  temperature  reaches  106°  Fahr.  or  107°  Fahr.  The 
roee-colored  spots  of  typhoid  are  never  present,  and  diarrhea 
rarely  exists.  And,  generally,  the  abdomen,  which  is  tympanitic 
in  typhoid  fever  is  flat  or  even  spaphoid  in  acute  tuberculosis. 

Influenza  which  at  times  closely  resembles  typhoid  fever,  may 
be  differentiated  by  the  short  duration  of  the  attack,  the  tempera- 
ture range,  and  the  general  absence  of  the  abdominal  symptoms 
of  typhoid.  ^ 

Pneumonia  with  typhoid  symptoms — typhoid  pneumonia — 
may  be  confounded  with  typhoid  fever.  In  the  former,  however, 
there  is  no  eruption,  and  the  temperature  curve  is  atypical.  The 
typhoid  symptoms  appefir  usually  during  the  second  stage  of  the 
pneumonic  inflammation,  and  are  either  preceded  or  attended  by 
cough,  and  the  characteristic  expectoration.  Physical  explora- 
tion of  the  chest  if  instituted  before  the  typhoid  state  supervenes 
will  elicit  positive  evidence  of  pneiunonic  consolidation. 

In  gastro-enteritis,  which  may  be  conf  ounc  ed  with  typhoid 
fever,  the  febrile  movement  is  usually  symptomatic,  and  preceded 
by  diarrhea  and  vomiting.  There  is  neither  eruption,  nor  en- 
largement of  the  spleen.  The  temperature  curve  is  atypical,  and 
the  disease  is  of  a  relatively  shorter  duration. 

Trichiniasis  occasionally  closely  resembles  typhoid  fever.  The 


*  is  occaBion- 
er  Bimulates 
,  malaise  and 
jastric  irrita- 
mnrked  epi- 
c-like odor  io 
c.  The  tem- 
bhe  normal  as 

0  per  minute. 

1  in  men,  and 
from  typhoid 
lelirium,  sub- 

Bordes.     Its 
ible  vision  or 

IB  of  typhoid 
r  early  in  the 
°  Fahr.  The 
and  diarrhea 
is  tympanitic 
aberculosis. 

aid  fever,  may 
:,  thetempera- 
nal  symptoms 

^eumcmia — 
•mer,  however, 
itypical.  The 
id  stage  of  the 
3r  attended  by 
^sical  explora- 
ate  supervenes 
iation. 

with  typhoid 
I,  and  preceded 
iption,  nor  en- 
is  atypical,  and 

loid  fever.  The 


PROGNOSIS. 

differential  diagnosis  rests  chiefly  upon  the  existence  of  intense 
muscular  pains  and  oedema  of  the  eyelids;  as  also  on  the  ab- 
sence of  epistaxis,  the  rose  spots  and  enlargement  of  the  spleen. 
A  microscopical  examination  of  the  muscolar  tissue  will  render 
the  diagnosis  positive. 

Prognosis. — Typhoid  fever  is  best  erdured  by  lean  and  mus- 
cular indi>iduals.  The  prognosis  is  always  bad  in  fat  and  gouty 
subjects,  and  in  persons  over  forty  years  of  age.  It  is  especially 
unfavorable  in  the  puerperal  state,  and  when  occurring  among 
the  intemperate. 

Death  may  occur  at  any  period  of  the  disease,  but  in  uncom- 
plicated cases  it  rarely  occurs  earlier  than  the  third  week.  It 
may  take  place  by  asthenia  at  the  end  of  the  third  or  in  the 
fourth  week.  It  may  occur  by  coma  at  the  end  of  the  second  or 
early  in  the  third  week.  Or  it  may  follow  sudden  collapse  after 
intestinal  hemorrhage,  perforation,  or  sudden  heart  failure,  any 
time  after  the  second  week  Liebermeister  says  that  in  all 
typhoid  patients  who  die  without  complications,  the  immediate 
cause  of  death  lies  in  the  fever  and  its  consequences.  The  pa- 
tients die  either  from  weakness  of  the  heart,  caused  by  the  rise 
of  temperature,  or  from  paralysis  of  the  brain.  Abortive  cases, 
those  in  which  the  pathological  processes  of  the  ileum  do  not 
go  on  to  sloughing,  terminate  abruptly  by  crisis  about  the  four- 
teenth day.  Typical  cases  always  terminate  by  prolonged  lysis, 
defervescence  being  completed  by  the  twenty-first  or  twenty- 
eighth  day.  A  second  attack  of  typhoid  fever  is  usually  milder 
than  the  first. 

The  daily  fluctuations  in  temperature  are  of  great  importance 
in  making  the  prognosis.  As  a  rule  the  greater  the  daily  fluct- 
uations the  more  favorable  the  prognosis.  But  a  sudden  rise  or 
fall  in  temperature  at  any  period  of  the  fever  is  of  bad  omen. 
Usually  the  more  sudden  the  appearance  of  the  disease,  and 
the  more  rapid  the  temperature  rise,  the  milder  the  attack  A 
continuously  high  fever  is  always  more  disastrous  to  the  system 
than  one  marked  by  morning  remissions.  The  temperature  at 
the  end  of  the  first  week  is  a  guide  for  the  coming  weeks.  A 
moderate  elevation  of  temperature  from  103°  Fahr.  to  105°  Fahr. 
at  this  time  indicates  that  the  disease  will  probably  run  a  favor- 
able course.  After  the  first  week  a  temperature  above  105° 
Fahr.,  if  prolonged,  renders  the  prognosis  unfavorable.    Slight 


wmmm 


MTlWftn 


':V 


170 


LECTUBE8  ON  FEVERS. 


decline  accompanied  by  great  fluctuation  of  temperature,  during 
the  third  week,  is  a  bad  symptom. 

In  civinK  the  i)ercentage  of  over  four  hundred  cases  observed 
in  the  hospital  at  Tknlo,  Wilson  wites,  that  of  those  J n  wh-m 
the  axillary  temperature  did  not  attain  104"  Fahr.  9.6  per  cent 
did  Of  those'ihat  reached  or  exceeded  104"  Fahr.  29.1  per 
cent  died.  Of  those  that  rose  to  or  beyond  105^  8  Fahr.  over  ,0 
per  cent  died.    And  of  those  that  exceeded  107°  Fahr.  nearly 

^  ne  state  of  tlic  pulse  is  an  important  elornent  in  prognosis 
A  full  and  regular  pulse  of  110  or  115  per  minute,  with  a  good 
heart  impulse  and  a  distinct  first  sound,  renders  the  prognosiB 
favorable,  even  if  the  temperature  is  high.  While  a  pulse  of  120 
or  130  with  a  feeble  impulse  and  an  indistinct  tiist  sound,  vitiates 
the  prognosis.  A  sudden  fall  of  the  pulse  from  any  cause  is  an 
unfavorable  symptom;  a  sudden  quickening  is  also  an  unfavor- 
able  indication  as  it  shows  extensive  cardiac  failure.  Cardiac 
weakness  favors  the  formation  of  blood  clots  in  the  heart  cavities, 
which  breaking  up  may  lead  to  embolism.  Venous  thrombosis 
does  not  vitiate  the  prognosis,  as  it  usually  ends  in  recovery. 

Incases  in  which  the  cerebral  symptoms  are  marked  and 
severe,  the  prognosis  should  be  guarded.  Cerebral  oedema,  an- 
nounced by  an  enfeebling  of  the  mental  powers  and  a  tendency 
to  stupor,  may  appear  as  a  complication  during  the  third  week, 
and  always  renders  the  prognosis  grave.  Cases  characterized  by 
persistent  delirium  usually  terminate  fatally. 

Intestinal  hemorrhage,  if  slight,  and  occurring  before  the 
twelfth  day,  is  regarded  by  some  as  beneficial,  but  if  copious  and 
occurring  after  the  twelfth  day,  it  is  an  unfavorable  symptom. 
Perforation,  which  is  more  frequent  amongst  men  than  women, 
is  a  dangerous  and  usually  fatal  complication. 

Laryngitis  may  in  protracted  cases  of  this  fever,  by  suddenly 
giving  rise  to  oedema  of  the  glottis,  endanger  life.  Capillary 
bronchitis  with  its  sub-crepitant  rales,  greatdyspncea  and  strinKSj 
expectoration,  coming  on  after  the  second  or  third  week,  if  at  all 
extensive,  is  an  unfavorable  indication.  (Edema  of  the  lungs, 
as  the  result  of  failure  of  heart  power,  may  appear  suddenly,  any 
time  after  the  third  week,  and  is  of  grave  import  An  extensive 
pne«monta-usually  catarrhal-accompani«d  by  irregular  varia 
tions  in  temperature,  and  developing  any  time  after  the  third 


PR00N08IH. 


171 


ture,  during 

BBS  observed 
jse  Jn  wh<  .m 
9.6  per  cent 
uhr.  29.1  per 
Fabr.  over  'jO 
Fabr.  nearly 

in  prognosis. 
,  witb  ft  good 
be  prognosis 
%  pulse  of  120 
ound,  vitiates 
ly  cause  is  an 

0  an  unf  avor- 
are.  Cardiac 
beart  cavities, 
as  tbrombosis 

1  recovery. 

)  marked  and 
ftl  oedema,  an- 
nd  a  tendency 
he  third  week, 
aracterized  by 


week,  is  especially  unfavorable.  The  chnnces  of  recovery  moy 
bowever,  be  good,  notwithstanding  tbe  occurrence  i)f  pueumoni- 
tis,  provided  the  inflammation  is  limited  to  one  lung. 

Acute  yasiric  catarrh,  due  to  dietetic  errors,  and  occurring  after 
tbe  fourth  week,  if  at  all  severo,  is  an  unfortunate  complication, 
and  lessens  tbe  chances  for  recovery. 

CellulUia  frequently  complicates  convalescence,  anil  may  cause 
death.  Bcd-aorca  moy  cause  death,  either  from  exhaustion,  or 
from  septic  poisoning.  Pregnancy  and  the  puerperal  state  al- 
ways unfavorably  influence  the  prognosis.  And  individuals  witb 
either  pulmonary  jjlithisis,  or  diabetes,  run  great  danger,  when 
taken  sick  witb  typhoid  fever. 


ig  before  the 
if  copious  and 
able  symptom, 
n  than  women, 

r,  by  suddenly 
fe.  Capillary 
cea  and  stringy 
i  week,  if  at  all 
I  of  tbe  lungs, 
r  suddenly,  any 
An  extensive 
irregular  varia- 
af  ter  tbe  third 


LECTURE  XII. 
Typhoid  Fever. -(Continued). 

TREATMENT. 

I  shall  to^ay  direct  your  attention  to  the  management  of  ty- 

phoid  fever. 

Before  entering  on  the  consideration  of  therapeutic  measures, 
it  may  however,  be  well  to  say  a  few  ^^ords  concerning  prevent- 
ive  treatment. 

Prophylaxis.— The  essential  point  in  the  prevention  of  the 
spread  of  typhoid  fever,  I  would  have  you  remember,  consists  m 
the  proper  treatment  of  the  dejections  of  the  sick.  So  success- 
fully  can  the  spread  of  the  morbific  agent  be  prevented,  that  next 
to  conducting  your  patient  to  a  successful  convalescence,  it  will 
be  your  highest  duty  to  see  to  it  that  no  new  cases  of  fe^-er  arise 
by  either  direct  or  indirect  infection  from  any  patient  under  your 
care  When  the  disease  appears  in  your  locality,  you  should,  il 
possible,  find  out  the  cause  of  the  infection,  remove  all  those 
surroundings  which  favor  the  reproduction  of  the  poison,  and 
take  immediate  steps  to  correct  whatever  conditions  lead  to  the 
pollution  of  drinking  water  or  of  the  air. 

In  order  to  destroy  the  germ,  which  is  contained  in  the  intes- 
tinal  discharges,  the  dejections,  before  being  thrown  out,  should 
be  promptly  and  thoroughly  disinfected.  For  this  purpose  a 
solution  of  chloride  of  zinc,  20  per  cent,  or  a  solution  of  carbolic 
acid  5  per  cent,  or  what  is  preferable,  Piatt's  chlorides  may  be 
used  Or  after  the  evacuations  have  been  received  into  a  porce- 
lain bed-pan,  the  bottom  of  which  has  previously  been  covered 
with  a  thin  layer  of  ferric  sulphate,  a  quantity  of  crude  muri- 
atic acid,  equal  to  one-third  or  one-half  the  amount  of  the 
172 


1 


PRINCIPAL   IIEMEDI£H. 


178 


ement  of  ty- 

tic  meaBures, 
ling  prevent- 

sntion  of  the 
er,  consists  in 
So  Buccess- 
ited,  that  next 
scence,  it  will 
of  fever  arise 
nt  under  your 
^ou  should,  if 
love  all  those 
e  XMsison,  and 
ins  lead  to  the 

i  in  the  intes- 
vn  out,  should 
his  purpose  a 
ion  of  carbolic 
orides  may  be 
i  into  a  porce- 
f  been  covered 
jf  crude  muri- 
imount  of  the 


discharge  should  be  pouiod  over  the  fecal  mass.  In  rund  dis- 
tricts— where  the  dittenso  numt  nboimilH—the  disinfected  dib- 
charges  Hhould  bo  eini)tied  into  tronrhcs  dug  anew  for  their  re- 
ception, and  carefully  covered  up.  Care  should  be  taken  to  locate 
these  trenches  a  sufficient  distance  frouj  wells  or  springs,  so  that 
drainage  from  them  may  not  contaminate  the  water  Hupi)ly.  In 
cities  and  in  localities  where  the  dejections  are  usually  emptied 
into  the  ordinary  water-closets  or  privy-vaults,  the  closets  or 
vaults  should  bo  immediately  tlushed  with  some  one  of  the  disin- 
fectant solutions  alreaily  enumerated. 

All  the  patient's  body  and  bed  linen,  and  especially  such  as 
have  been  soiled  with  the  excreta,  bef(jre  being  removed  from 
the  room  (daily),  should  be  thrown  into  a  five  per  cent  solution 
of  carbolic  acid,  or  some  other  disinfectant,  and  then  immedi- 
ately washed.  Piatt's  chlorides  should  be  sprinkled  on  the  bed 
and  about  the  room,  and  after  the  death  or  euro  of  the  patient, 
charcoal  should  be  burnt  in  the  apartment  with  sublimed  sulphur, 
and  the  room  closed  for  twenty -four  hours.  Before  the  room  is 
again  occupied  it  should  be  washed  with  carbolized  water,  and 
freely  aired  for  at  least  one  week. 

When  the  disease  is  prevailing  as  an  endemic,  Bapiiaici,  first 
dil.  administered  morning  and  evening,  often  acts  as  a  preventive 
by  rendering  the  system  less  susceptible  to  the  morbific  ageni 

Principal  Remedies. — Typhoid  fever  being  a  self-limited  dis- 
ease, it  cannot  be  cut  shoi-t,  after  the  morbific  agent  has  fully  in- 
vaded the  organiam,  by  any  known  method  of  treatment.  In  ex- 
ceptional cases,  if  you  are  fortunate  enough  to  be  called  to  a  pa- 
tient before  the  poison  has  fully  invaded  the  organism — and  that 
is  before  the  appearance  of  any  definite  symptoms  that  will  en- 
able you  to  diagnose  typhoid  fever — and  are  still  more  fortunate 
to  have  prescribed  Baptisia  or  Bryonia,  you  may  perchance  assist 
the  case  to  assume  either  the  mild  or  abortive  type.  Otherwise, 
to  use  a  nautical  phrase,  you  must  be  content  simply  to  steer  the 
ship,  for  you  can  neither  shorten  nor  alter  the  course  of  the  storm, 

.  Baptisia  may  be  justly  considered  our  sheet  anchor  in  the 
treatment  of  typhoid  fever  during  the  first  week.  For  it  is  ca- 
pable of  exciting  a  fever  resembling  that  of  typhoid,  and  of  pro- 
ducing congestion  and  catarrhal  inflammation  of  the  intestinal 
mucous  membrane,  with  abdominal  tenderness  and  diarrhea,  the 


\ 


174 


LECTURES  ON  FEVERS. 


^ 


pathological  condition  present  during  this  period.  The  soft  and 
full,  yet  quick  pulse,  the  headache  and  tendency  to  delirium,  the 
despair  of  cure,  the  fetid  breath,  the  soreness  all  over,  and  the 
intolerance  of  pressure  on  lying  are  marked  symptoms.  It  is 
best  indicated  in  that  type  which  is  characterized  by  extreme 
depression  of  vitality.  And  if  administered  early,  it  will  con- 
siderably abate  its  energy. 

Bryonia  is  an  older  and  more  tried  remedy  than  Baptisia.  It 
is  mainly  useful  in  moderately  severe  cases,  and  is  characteris- 
tically indicated  for  the  symptoms  prior  to  the  stage  of  ulcera- 
tion. Nervous  symptoms  do  not  eontra-indicate  it,  especially  if 
there  is  mild  delirium  at  night  ubout  the  affairs  of  the  previous 
day  or  business  matters.  Besides  being  adapted  to  the  general 
symptoms  of  the  early  stages  of  the  fever,  this  remedy  has  a 
specific  action  on  the  bronchial  tubes.  Sometimes  it  suffices, 
unaided,  to  bring  the  disease  to  a  favorable  termination. 

Bhus  iox.iB  adapted  to  the  more  intense  cases,  and  corresponds 
to  all  stages,  but  more  especially  to  the  period  of  fully  developed 
intestinal  affection.  It  supersedes  Bryonia  as  soon  as  the  charac- 
teristic stools  appear,  and  is  particularly  indicated  when  the 
dejections  are  copious  and  of  a  cadaverour.  odor,  when  the  tongue 
is  brown  and  parched  and  presents  tho  red  triangular  tip,  and 
when  the  rheumatoid  tearing  pains  in  the  joints  are  worse  dur- 
ing rest.  In  whatever  stage  this  remedy  is  indicated,  the  func- 
tions of  vegetative  life  will  be  found  excited  and  ovbr-active, 
while  those  of  animal  life  will  be  depressed. 

Arsenicum  alb.  takes  the  place  of  Bhus  tox.,  when  the  latter 
fails  to  control  the  critical  evacuations,  and  a  graver  erethitic 
state  supervenes.  It  is  especially  useful  during  the  second  half 
of  the  second  and  during  the  third  week.  It  is  the  remedy  when 
the  stools  are  dark  in  color  and  offensive,  and  when  bed  sores 
appear  early  in  the  disease.  Frequent  urging  to  urinate,  with 
burning  and  scanty  discLarge  is  speedily  relieved  by  its  admin- 
istration. 

When  vegetative  and  animal  life  are  simultaneously  depressed, 
and  in  consequence  of  the  excessive  prostration  the  patient  lies  in 
a  state  of  stupid  apathy  and  indifference,  Phosphoric  acid  is  the 
remedy.  At  the  onset  of  the  disease  you  will  often  find  it  in- 
Taluable  in  arresting  the  diarrhea,  especially  when  the  discharges 


—'I 


L  The  soft  and 
to  delirium,  the 
11  over,  and  the 
jrmptoms.  It  is 
ized  by  extreme 
irly,  it  will  con- 

an  Baptisia.  It 
d  is  characteris- 
stage  of  ulcera- 
)  it,  especially  if 
of  the  previous 
id  to  the  general 
is  remedy  has  a 
times  it  suffices, 
nination. 

and  corresponds 
fully  developed 
}nas  the  charac- 
cated  when  the 
when  the  tongue 
iangular  tip,  and 
8  are  worse  dur- 
icated,  the  func- 
and  ovbr-active, 

,  when  the  latter 
graver  erethitic 
;  the  second  half 
he  remedy  when 
when  bed  sores 
to  urinate,  with 
3d  by  its  admin- 

ously  depressed, 
be  patient  lies  in 
horic  acid  is  the 
often  find  it  in- 
n  the  discharges 


PBINCIPAL  BEHEDIES. 


175 


are  yellow  and  watery,  and  the  tongue  is  pale,  moist,  and  thinly 
coated.  It  is  an  important  remedy  in  mild  typhoids  attended 
with  dullness  of  hearing  and  great  nervous  prostration.  Lyco- 
podium  preceded  by  a  few  dose:,  of  Calcarea  carh,  is  said  to 
ameliorate  the  symptoms,  when  the  eruption  is  delayed,  and 
there  are  muttering  delirium,  carphologia,  and  tympanites. 

When  symptoms  of  putrid  decomposition  of  the  fluids  appear 
you  will  think  of  Muriatic  acid.  It  is  the  best  remedy  for  the 
putrid  sore  throat  which  sometimes  occurs  as  a  complication. 
And  it  may  occasionally  be  of  service  in  hemorrhages  from  intes- 
tinal ulceration  when  Nitric  acid  fails.  A  sliding  down  in  bed  is  a 
marked  characteristic.  The  Mercuric  cyanide  may  prove  an 
efficient  remedy  when  ulcerative  oaanges,  attended  with  great 
prostratioij,  take  place  in  the  pharynx  and  larynx.  Nitric  acid 
will  do  good  service  when  the  evacuations  consist  of  greenish 
mucus,  and  the  tongue  is  thickly  coated  white.  It  is  our  main 
remedy  in  intestinal  ulceration  with  hemorrhage,  vrhen  the 
blood  is  fresh  and  of  a  bright  red  color.  Profuse  passive  hem- 
orrhages call  for  ^rwsote  or  JfarwaiweZiae.  Terebinihina  should 
be  substituted  when  with  the  hemorrhage  from  the  bowels  there 
is  extreme  tympanites,  and  retention  of  urine.  Urinary  reten- 
tion is  best  relieved  by  the  catheter,  whick  should  be  used  when 
necessary  twice  a  day.  Our  best  remedy  to  prevent  a  recurrence 
of  the  retention  is  unquestionably  Opium. 

Phosphorus  supplements  Phosphoric  acid,  and  is  indicated 
when  the  disease  assumes  an  adynamic  type.  Its  stools  are  pain- 
less, profuse,  and  either  resemble  flesh  vater  or  are  black  like 
coffee  dregs.  Frequently  there  is  watery,  bilious  vomiting  in 
the  first  and  at  the  beginning  of  the  second  period.  It  frequent- 
ly arrests  the  preliminary  diarrhea  of  the  first  week,  and  is  in- 
valuable for  colliquative  diarrhea  occurring  as  a  sequel.  Phos- 
phorus is  an  efficient  remedy  when  Bryonia  fails  to  relieve  the 
catarrhal  and  pulmonary  difficulties,  and  when,  towards  the  end 
of  the  second  period,  there  is  a  tendency  to  hypostatic  consoli- 
dation, or  pneumonia.  Spongia  will  occasionally  be  of  service 
when  laryngeal  symptoms  predominate.  Senega  follows  Tartar 
emet.,  in  the  treatment  of  the  bronchitis,  and  is  adapted  to  that 
passive  form  which  is  attended  with  copious  secretion  and  a  de- 
pressed state  of  system.  Tartar  emet.  may  prove  useful  when 
•oedema  of  the  lungs  threatens,  and  there  is  gi-eat  rattling  of  ac- 


iilillii 


176 


LECTURES  ON  FEVERS. 


cumulated  mucus  in  the  chest.  Should  the  mucus  accumulatiott 
at  any  time  threaten  to  cause  paralysis  of  the  lungs  and  asphyxia, 
Moschns  will  be  your  best  remedy. 

Mcrcurius  dulcis  may  be  useful  daring  the  second  period,  es- 
pecially when  there  is  danger  of  perforation  from  deep  ulcera- 
tion of  the  glands  of  Peyer.  It  may  be  given  when  the  evacua- 
tions become  more  frequent  at  night,  and  are  greenish  or  yellowish 
in  color,  provided  the  tongue,  whicH  is  usually  thickly  coated,  re- 
mains  moist,  and  there  is  no  delirium.  When  peritonitis  occurs 
without  perforation,  you  will  think  of  Mercurius  cor.  In  ex- 
treme cases,  as  your  dernier  resort,  I  may  mention  Carbo  veg., 
— a  remedy  which  will  frequently  render  you  excellent  service, 
in  overcoming  that  complete  torpor  of  vital  functions,  which 
neither  phosphorus,  muriatic  acid,  rhus  tox.,  nor  arsenicum  have 
the  power  to  remove.  Along  with  well-timed  alcoholic  stimu- 
lation, it  may  prove  useful,  if  at  any  time  the  functional  powers 
of  the  heart  speedily  fail. 

Belladonna  may  prove  efficacious  as  an  intercurrent  remedy, 
when  early  in  the  disease  the  patient  becomes  delirious,  sees  all 
sorts  of  frightful  phantasms,  and  no  longer  recognizes  his  f riends- 
and  relatives.  It  is  the  remedy  for  the  early  bronchial  compli- 
cations in  children,  and  also  for  the  pharyngeal  spasms  which 
occasionally  occur  later  on  in  the  disease.  Hyoscyamus  maybe 
needed  when  the  delirium  is  continuous  and  does  not  yield  to 
Belladonna.  At  any  stage  the  occurrence  of  lascivious  mania, 
on  the  one  hand,  or  the  sinking  of  the-  patient  into  a  state  of 
apathetic  stupefaction,  on  the  other,  is  a  strong  indication  for- 
this  remedy.  In  the  higher  degrees  of  delirium.  Stramonium 
is  frequently  the  appropriate  remedy,  especially  when  there  is 
great  loquacity,  and  a  mania  for  light  and  company.  Valerian 
sometimes  comes  to  the  rescue,  when  bell.,  hyosc,  and  stram., 
all  fail. 

Opium  will  be  of  service  when  there  is  considerable  stupor 
and  but  little  fever,  or  when  mild  delirium  alternates  with  stu- 
por or  stertorous  breathing.  It  i.>  the  first  remedy  you  will 
think  of  when  sopor  threatens  to  terminate  in  paralysis  of  the 
brain,  and  if  it  fails,  Lachesis  may  cause  the  desired  reaction, 
especially  if  with  the  soporous  condition  there  is  dropping  of 
the  lower  jaw.  When  the  stupefaction  is  attended  with  involun- 
tary discharges  of  stool  and  urine  Arnica  may  be  compared. 


ssn 


LEADING  INDICATIONS. 


177 


laccumulation 
md  asphyxia, 

id  period,  es- 
deep  ulcera- 
the  evacua- 
or  yellowish 
ly  coated,  re- 
mitis  occurs 
cor.  In  ei- 
n  Carbo  veg., 
silent  service, 
ctions,  which 
jenicum  have 
oholic  stimu- 
tional  powers 

rrent  remedy, 
rious,  sees  all 
ses  his  friends 
ichial  compli- 
spasms  which 
ijamua  maybe 
8  not  yield  to 
ivious  mania, 
into  a  state  of 
udication  for 
,  Stramonium 
ivhen  there  is 
y.  Valerian 
.,  and  stram., 

jrable  stupor 
ites  with  stu- 
Bdy  you  will 
•alysis  of  the 
ired  reaction, 
I  dropping  of 
with  iuvolun- 
ampared. 


Occasional  intercurrent  remedies  are:  Merc,  sol  or  Ledtim  for 
the  epistaxis  in  the  first  period.  Phosphorus  for  epistaxis  in  the 
later  periods.  Bell,  or  Merc.  viv.  for  the  parotitis.  Laurocera- 
sua  for  the  clonic  convulsions  of  the  limbs.  Veratrum  alb.,  if 
weakness  remains  after  the  critical  periods  have  passed.  Carbo 
veg..  Fluoric  acid.,  or  Secale  for  the  bed  sores.  Cocculus  for 
loss  of  appetite.  Cinchona  for  excessive  hunger,  and  Nux  vom. 
for  indigestion,  during  convalescence.  And  Psorinum,  Alstonia 
or  Sulphur  for  protracted  convalescence. 

Leading  Indications. — The  guiding  symptoms  for  these  our 
main  remedies  in  typhoid  fever,  as  well  as  for  others  occasion- 
ally of  service,  may  be  compiled  as  follows: 

Agaricusmnsc. — Disinclined  to  answer  questions  {phos.  acid). 
Desire  for  alcoholic  drinks.  Sensitive  smell  (colch.).  Dry 
tongue  with  dryness  and  constriction  in  the  fauces.  Rumbling 
in  the  bowels  with  the  passage  of  much  inodorous  flatus.  Tremor 
of  the  hands.  Aching  along  the  ppine  and  limbs.  Pains  in  the 
legs  especially  in  the  hip  joints.  Twitchings  of  the  gluteal 
muscles.    Cramps  of  the  hands  and  feet. 

Apis.  mel. — Muttering  delirium.  Sopor  interrupted  by  pierc- 
ing shrieks.  Tongue  swollen,  dry,  cracked,  ulcerated,  and  pro- 
truded  with  difficulty  {ars.,  rhus).  Great  soreness  in  the  pit 
of  the  stomach  when  touched  {bry.).  Swollen  abdomen,  sore 
to  the  touch  (lach.).  Stools  occur  with  every  motion  of  the 
body  (phos.).  Suppression  of  urine  (hyos.).  White  miliary 
eruption  on  the  abdomen.  Tired,  feeling  as  if  bruised  in  back 
and  limbs  {rhus.).  Carbuncles  with  burning,  stinging  pains 
(ars.).    Great  weakness,  and  sliding  down  in  bed,  (rrmr.  acid.). 

Arnica. — Patient  sits  in  a  semi-stupid  state.  Appears  to  be 
absorbed  in  deep  thought  yet  tt  ^nks  of  nothing.  Forgets  the 
word  while  speaking  {baryta,  rhui  ).  Declines  to  answer  ques- 
tions {phos.  acid  )  Thinks  he  \i  well  {ars.).  Confused  feel- 
ing in  the  head  with  pressure  over  the  right  brow.  Unref  resh- 
ing  sleep  with  anxious  dreams.  Muttering,  and  loud  blowing 
during  expiration.  Delirium.  Stupor.  Great  weariness,  and 
prostration.  A  bruised,  sore  feeling,  the  bed  feels  too  hard 
{bapt).  Epistaxis.  Trembling  of  the  lower  lip.  Tongue 
coated  white,  or  dry  with  a  brown  streak  in  the  middle  {bapt). 
Taste,  breath  and  perspiration  offensive.    Abdomen  distended. 


178 


LECTURES  ON  FEVERS. 


Involuntary  discharges  of  urine  and  fteces  (ars.,hyos.).  Vio- 
lent stitches  in  the  middle  of  the  left  chest  (bry.).  Lassitude 
and  sluggishness  of  the  whoLj  body.  Great  sinking  of  strength, 
Petechiae.     Ecchymoses. 

Arsenicum  alb. — Great  restlessness  and  anxiety.  Constant 
motion  of  the  head  and  limbs.  Drawing  pressive  pain  in  the 
right  side  of  the  forehead.  Deathly  color  of  the  face  (carho 
ve<j.).  Cachectic  look,  sunken  hippocra tic  countenance  {ver. 
alb.).  Grinding  of  the  teeth  {hell,  hyoa.).  Dropping  of  the 
lower  jaw  (Zac/t.).  Circumscribed  redness  of  the  cheeks.  Hard- 
ness of  hearing.  Lips  dry  and  cracked  ar.d  covered  with  sordes. 
Tongre  red,  dry  and  cracked  {bry.,  rhus  ).  Black  leather-like 
tongue.  Dryness  of  the  mouth  with  violent  thirst.  Drinks 
often,  but  little  at  a  time  {bell.,  opp.  bry.).  Unintelligible  ar- 
ticulation as  if  the  tongue  was  too  heavy  (carfto  veg.).  Intense 
burning  pains  in  the  stomacli  and  pit  of  the  stomach  {phos., 
vcrat.  alb. ).  Violent  and  incessant  vomiting.  Meteoristic  dis- 
tension of  the  abdomen  with  gurgling  {lycop.,  hyos.,  terebinth.). 
Ileo-caecal  region  sensitive  to  the  touch  {mere,  phos.  acid  ). 
Brownish  or  watery,  fetid,  involuntary  stools.  Involuntary  mic- 
turition (%os.).  Eetention  of  urine.  Voice  weak,  trembling, 
hoarse.  Difficult  breathing  with  great  anguish.  Very  tenacious 
mucus  in  the  chest  {tart,  emet.,  kali  bich.).  Extensive  pul- 
monary hypostasis.  Pulse  frequent,  hard  and  tense,  or  small, 
trembling  and  intermittent.  Irregular  action  of  the  heart,  ab- 
sence of  the  second  sound.  White  miliary  eruption  {loch., 
mur.  acid).  Petechise  {rhus,  secale ,  am.).  Boils  {mere, 
sil,  sid.).  Bed-sores  {carbo.  veg.,  fluoric  acid  ).  Great  weak- 
ness and  prostration.  Rapid  emaciation  {secale).  (Edematous 
swelling  of  the  feet.  Cold  clammy  sweat.  Cadaverous  odor. 
Eose-colored  spots  on  the  chest  and  abdomen.  Symptoms  worse 
from  1  to  3  A.  M. 

Arum  triph. — Lips  and  corners  of  the  mouth  sore,  cracked 
and  bleeding.  Swelling  of  the  submaxillary  glands  and  neck. 
Tongue  sore,  red,  with  elevated  papilljt*.  Fetid  breath.  Excess- 
ive salivation.  Boring  of  the  nose.  Great  restlessness,  desires 
to  escape,  although  perfectly  conscious  of  what  he  is  doing,  and 
of  what  is  said  to  him. 

Baptisia. — Confusion  of  ideas  {gels. ).    Great  nervous  rest- 


1. 


LEADING  INDICATIONg. 


179 


\yos. ).     Vio- 

Lassitude 

of  strength, 

Constant 
pain  in  the 
face  (carbo 
inance  (ver. 
•ping  of  the 
eeks.  Hard- 
with  sordes. 
leather-like 
rst.     Drinks 
telligible  ar- 
g.).   Intense 
mach  {phos., 
jteoristic  dis- 
.,  terebinth.), 
phos.  acid  ). 
)luntary  mic- 
£,  trembling, 
ery  tenacious 
tensive   pul- 
ise,  or  small, 
he  heart,  ab- 
ption  (lack, 
oils    (mere, 
Great  weak- 
CEdematous 
TOrous  odor, 
iptoms  worse 

ore,  cracked 
Ib  and  ueck. 
ith.  Excess- 
less,  desires 
3  doing,  and 

ervous  rest- 


lessless.  Ca'^not  s'eep  because  the  head  feels  scattered  about 
and  she  cannot  get  the  pieces  together.  Stupor.  Heavy  sleep, 
the  patient  can  scarcely  be  aroused  long  enough  to  answer  n 
question.  Falls  asleep  in  the  midst  of  attempted  answers 
(arnica,  hyos.).  Face  dark  red  with  a  besotted  expression. 
Head  and  face  feel  numb.  Sordes  on  the  teeth  and  lips.  Mouth 
and  tongue  very  dry.  Fetid  breath.  Tongue  swollen  and 
thick.  White  furred  tongue  with  red  edges.  Yellow  or  yellow- 
ish-brown coating  along  the  center  of  the  tongue.  Bitter,  flat  or 
putrid  taste  in  the  mouth.  Fetid,  exhausting  stools  (ars.). 
Fetid,  dark  red  uri?  .e.  Tired,  bruised,  sick  feeling  in  all  parts  of 
the  body.  '  Feelij  ,^  as  if  the  lower  limbs  wer^  severed  from  the 
body  {opium).  Sensation  as  of  a  second  self  alongside  in 
bed.  Patient  changes  position  frequently  because  the  bed  be- 
comes too  hard  (arnica  ). 

Belladonna. — Starting,  jumping  during  sleep.  Sleepiness 
but  cannot  sleep  {loch., opium).  Violent  delirium.  Constant 
desire  to  spring  out  of  bed  (hyos.).  Attempts  to  bite,  strike 
and  spit  at  the  attendants  (hyos.,  opium).  Violent  throbbings 
in  the  brain.  Throbbing  of  the  carotids  (glon.).  Pressive  pain 
in  the  forehead,  obliging  him  to  close  the  eyes.  Sparkling,  star- 
ing eyes  (%os.,  s^aw.).  Intolerance  of  light  and  noise.  Face 
red,  swollen  and  hot.  Dryness  of  the  mouth,  tongue  and  throat 
Tongue  red  at  the  edges  and  white  in  the  center  {gels. ).  Trem- 
Uing  and  heaviness  of  the  tongue  with  thick  speech  {loch.). 
Fluids  escape  through  the  nose  {kali  hich.,  lack.).  Sore  throat, 
or  a  feeling  as  of  a  lump  in  the  throat  which  induces  hawking. 
Tenderness  of  the  abdomen  aggravated  by  the  least  jar.  Beten- 
tion  of  urine.  Involuntary  urination.  Dry  spasmodic  cough, 
worse  at  night  {dros.,  hyos.).  Pains  come  and  go  suddenly. 
Starts  as  if  in  affright  on  awaking  or  during  sleep. 

Bryonia. — Exceedingly  irritable  and  inclined  to  be  angry 
{cham.).  Easily  offended.  Wants  to  go  home.  Hasty  speech 
(  heparsid. ).  Violent,  oppressive,  stupefying  headache.  Vertigo 
with  sensation  as  of  the  head  turning  in  a  circle  {bell. ).  Visions 
when  closing  the  eyes.  Nightly  delirium,  especially  about  the 
affairs  of  the  previous  day  or  business  matters.  Buzzing  in  the 
ears  with  hardness  of  hearing.  Nose-bleed,  especially  in  the 
morning  on  rising.     Face  red,  hot  and  puffy.     Lips  dry,  brown 


180 


LECTURES   ON   FEVERS. 


m'    t 


nnd cracked.  Tongue  thickly  coated  white  {mere.)  or  yellowish. 
Dry  feeling  in  the  mouth.  Intensely  bitter  taste  (nux).  Ex- 
cessive thirst;  drinks  large  quantities  at  a  time.  Nausea,  or 
even  vomiting,  after  every  meal.  Cannot  sit  up  from  nausea  and 
faintness.  Vomiting  first  of  bile,  then  of  fluids  (opp.,  naf.  Tnt/n), 
Epigastric  region  painful  to  touch  and  pressure  {ars.,  nux). 
Acute  pains  in  the  ileo-csecal  and  splenic  regions.  Offensive 
stools.  Dark,  almost  brown  urine.  Dry  hacking  cough,  with 
stitches  in  the  chest  and  region  of  the  liver  {hell,  mere. ).  Full, 
hard  and  rapid  pulse.  Pain  in  the  back  and  limbs  when  mov- 
ing. Kestless  sleep,  with  moaning,  and  with  chewing  motions. 
Great  weakness  and  exhaustion. 

Calcarea  carb. — Great  anxiety  with  palpitation  of  the  hearir 
{cact,  spig.).  Vertigo.  Heaviness  in  the  forehead.  Hard- 
ness of  hearing.  Epistaxis,  especially  in  the  morning  {bry.). 
"White  coating  on  the  tongue  {mere).  Sleeplessness  from  sam& 
idea  arousing  him  from  slumber.  Abdomen  hard  and  distended. 
Soreness  in  chest  on  inspiration.  Short  hacking  cough.  Ex- 
cessive diarrhea.  Ravenous  hunger,  or  else  loss  of  appetite. 
Profuse  sweat  every  morning,  and  from  the  slightest  exertion. 
Great  weariness  of  the  limbs  as  after  a  long  walk.  Tendency  to 
obesity. 

Camphor. — Sudden  and  great  sinking  of  strength  {ars.). 
Extreme  restlessness  and  anxiety  (ars.).  Cold  sweat  all  over 
{verat.  alh.).  Cold,  pointed  nose.  Face  pale  and  anxious. 
Coldness  of  the  limbs  {ars.,  verat.).  Cramps  of  the  calves 
{sulph.).  Small,  weak,  scarcely  perceptible  pulse  {carboveg.). 
Violent  delirium.  Dullness  and  heat  of  the  head  with  cold,  clammy 
skin.  Tongne  cold  {carbo  veg.,  verat.  alb.).  Great  thirst.  Roll- 
ing and  rumbling  in  the  bowels  with  involuntaiy  evacuations. 

Carbo  veg. — Restlessness  and  anxiety.  Greenish  color,  or 
great  paleness  of  the  face  {ars.).  Hippocratic  countenance 
{verat.  alb.).  Severe  nose-bleed  several  times  daily.  Dullness 
of  the  eyes,  pupils  insensible  to  light.  Loss  of  hearing.  The 
gums  are  painfully  sensitive  while  chewing.  Cold  breath  and 
tongue.  At  times  the  tongue  is  moist  and  sticky.  At  others  it 
is  dry  and  cracked.  Hawking  of  mucus  in  the  throat.  The  epi- 
gastric region  is  distended.  Frequent  and  violent  eructations 
{puis. ).      Flatulent  distention  of  the  abdomen.      Emission  of 


(•l^aafir,^ 


CT'y- — 


LEADING   INDICATIONS. 


181 


or  yellowislu 
(niix).  Ex- 
Nausea,  or 
|m  nausea  and 
|p.,  nat  miir. ). 
{ars.,  mix), 
s.  Offensive 
cough,  with 
mere).  Full, 
IS  when  mov- 
i^^ing  motions. 

I  of  the  heart 
head.  Hard- 
)ming  {hry.). 
Jss  from  same 
md  distended, 
cough.  Ex- 
of  appetite, 
itest  exertion. 
Tendency  to 

ength  {ars.). 
jweat  all  over 
and  anxious, 
of  the  calvea 

(carbo  veg.). 

cold,  clammy 
thirst.  RoU- 
vacuations. 

ish  color,  or 
countenance 
y.  Dullness 
earing.  The 
d  breath  and 
At  others  it 
it.  The  epi- 
t  eructations 
Emission  of 


large  quantities  of  offensive  flatus.  Colliquative  diarrhea,  putrid 
and  involuntary  (ar.s.).  Diarrhea  during  convalescence.  Bron- 
chial catarrh  with  difficult  expectoration  of  tenacious  mucus. 
Loud  rattling  in  the  chest.  The  pulse  is  thread-like  and  scarcely 
perceptible.  Coldness  of  the  surface.  Cold  sweat  on  the  limbs. 
Cold  breath.  Threatened  paralysis  of  the  lungs  and  heart.  Bed 
sores  {ars.,  flumnc  acid,  secale). 

Cinchona. — Sense  of  internal  illness  as  of  impending  disease. 
Frequent  nose-bleed,  especially  in  the  morning  {hry.).  Pale, 
earthy,  grayish-yellow  complexion  {ars. ).  Constant  inclination 
to  stretch  the  limbs  or  change  position.  Enlargement  of  the 
liver  and  spleen.  Bitter  or  sour  taste.  Empty  eructations. 
Milk  deranges  the  stomach  {sulph.).  Tympanites.  Painless, 
indigested  stools  {jpodo. ).  Profuse  sw^at  during  sleep,  espe- 
cially on  the  side  on  which  the  patient  lies.  Great  weakness. 
Protracted  convalescence.  , 

Coccnlns. — Slowness  of  comprehension.  Very  sensitive  mood. 
Tertigo  with  nausea  when  rising  up  in  bed  (bry. )  must  lie  down. 
Stupor.  Coma  vigil.  Heaviness  of  the  lids.  Noise  in  the  ears 
like  the  rushing  of  waters.  Metallic,  coppery  taste  with  loss  of 
appetite  {ars.,  rhus).  Nausea  with  tendency  to  faint.  Drink 
rolls  audibly  down  the  throat  {hydr.  acid  ).  Great  distention 
and  rumbling  in  the  abdomen.  Weakness  of  the  cervical  mus- 
cles. Feet  and  hands  fall  asleep  alternately.  Great  general 
weakness  and  weariness  after  over-exertion. 

Colchicum. — External  impressions,  especially  strong  odors, 
■disturb  the  patient.  Dullness  of  perception.  Delirium  with 
headache  (beW.).  Sudden  sinking  of  the  vital  forces.  Cadaverous 
appearance.  Hollow  staring  eyes.  Lips,  teeth  and  tongue  covered 
with  sordes.  Skin  dry.  Nose-blee  1  evenings.  Body  hot.  Hands 
and  feet  cold.  CoM  sweat  on  forehead.  Tongue,  heavy,  stiff 
and  insensible  (con.).  Tongue  protruded  with  difficulty.  Grind- 
ing of  the  teeth  {hell,  hyos.).  Epigastrium  extremely  sensi- 
tive to  pressure  {bell.).  Violent  binning  or  icy  coldness  in  the 
stomach  {ars.).  Great  thirst.  Distention  of  the  abdomen. 
"Watery  diarrhea.  Involuntary  stools.  Dark,  liquid,  offensive, 
painftd  stotilH.  Suppression  of  urine.  Involuntary  micturition. 
Irregular  intermittent  respirations.  Small,  quick,  scarcely  per- 
ceptible pulse.     CEdemntous  swelling  of  llie  legs  «nd  feet  {ars.). 


i 


182 


LECTURES  ON   FEVERS. 


Great    exhaustion    and    weakness    as  after  exertion,    in     the 
autumn. 

Oelseniinm. — In  the  prodromic  period.  Dullness  of  the  men- 
tal facuKies  {hapt).  Trembling  from  weakness.  Vertif;o  and 
blurred  vision  (tm  vers.).  Drowsiness,  vertigo,  and  great 
muscular  prostration.  Heaviness  of  the  head,  relieved  after 
profuse  emission  of  watery  urine  [phos.  acid).  Severe  pains 
in  the  head,  back  and  extremities.  The  brain  feels  as  if  bruised 
{hell.).  Head  feels  as  "big  as  a  bushel."  Cephalalgia  with 
aching  lancinating  pains  extending  from  the  left  occipital  region 
through  the  head  to  the  forehead  and  eyeballs.  Drooping  of 
the  eyelids  {caust).  Heavy,  besotted  expression  {hapt).  Crim- 
son ilush  of  the  face.  Tongue  coated  yellowish-white.  Can 
hardly  protrude  it,  it  trembles  so  {hell.,  lack.,  secale).  Numb- 
ness of  tongue,  feels  so  thick,  can  hardly  speak  {caust).  Iliac 
tenderness.  Chilliness.  Coldness  of  the  hands  and  feet.  Com- 
plete prostration  of  the  entire  muscular  system 

Hamamelis. — Great  lassitude  and  weariness  of  the  limbs. 
Extreme  soreness  of  the  abdomen.  Bloody  alvine  dejections  of 
tar-like  consistency  {alumen,  black).  Profuse  nose-bleed  with 
feeling  of  tightness  of  the  bridge  of  the  nose  {dulc). 

Helleborus  nig. — Sensation  of  soreness  of  the  back  part  of 
the  head  with  stupei^ction.  Eyes  vacant,  pupils  dilated  {hell.^ 
hyos.).  Insensibility.  Slow  of  comprehension.  Lies  in  a  state 
of  constant  slumber.  Utters  no  complaint.  Chewing  motions 
of  the  jaws  ( hry. ) .  Convulsive  twitching  of  the  muscles  ( cupr. ). 
Bliding  down  in  bed  {mur.  acid).  Small,  slow,  tremulous  pulse. 
Trifling  loss  of  flesh. 

Hyoscyamiis. — Complete  loss  of  consciousness  {bell.,  opium). 
Coma  vigil.  Muttering  with  picking  at  the  bed-clothes  {opiuvi ). 
Muttering  loquacity  {apis).  Answers  questions  correctly,  when 
asked,  but  lapses  again  into  delirium  {nmica,  bell.).  Whines 
and  don't  know  why.  Inability  to  direct  the  thought.  Sleep- 
lessness or  constant  muttering  sleep.  Constant  delirium  with 
great  restlessness.  Jumping  out  of  bed.  Thinks  he  is  in  the 
wrong  place.  Attempts  to  run  away  {bell.,  bry.).  Desires  td 
uncover  and  remain  naked.  Flushed  face,  stupid  expression 
{hapt.).  Eed,  staring,  sparkling  eyes  {bell.).  Pupils  dilated 
(bell.  )  and  insensible  {opium).     Objects  appear  red  as  fire,  of 


LEADING    INDICATIONS. 


183 


lertion,   in    the 

tieHsof  the  men- 
Vertipo  and 
tigo,   and  great 
relieved  after 
Severe  pains 
(Is  as  if  bruised 
iphalalgia  with 
occipital  region 
i.    Drooping  of 
(bapt).   Crim- 
sh-white.     Can 
cale).     Numb- 
(musi).    Iliac 
md  feet.     Com- 

of  the  limbs, 
le  dejections  of 
nose-bleed  with 
lie. ). 

le  back  part  of 
8  dilated  {bell, 
Liesinastate 
lewing  motions 
mscles  (cujyr. ). 
•emulous  pulse. 

(bell,  opium). 
othes  {opium). 
jorrectly,  when 
bW.).    Whines 
>ught.    Sleep, 
delirium  with 
:s  he  is  in  the 
I.     Desires  to 
id  expiession 
*upils  dilated 
red  as  fire,  ot 


too  large  {o\)Y). plat,).  Deafness.  Constrictive  sensations  in  the 
throat  with  inability  to  swallow  {bell,  strain.).  Clean, parched, 
dry  tongue.  Much  thirst.  Hiccough.  Putrid  breath.  Invol- 
untary stools  at  night  {ura.,  rhua).  Retention  of  urine.  In- 
voluntary urination.  The  urine  leaves  reddish  streaks  on  the 
sheet  (Z»/c'o/>.).  Grating  of  the  teeth  {apis,  hell).  Trembling 
of  the  limbs.  Subsiiltus  tendinum  {phos.  acid).  Rose  spots 
on  the  chest  and  abdomen. 

Ignatia. — ^Great  impatience.  Changeable  disposition.  Sen- 
sation as  if  swinging  to  and  fro  in  a  swing.  Broods  over  im- 
aginary troubles.  Flickering  zigzags  before  the  eyes.  Frequent 
sighing.  Over-sensitive  t(j  pain  {coffea).  Sour  taste  in  the 
mouth.  Convulsive  motions  of  the  face  and  extremities  {strum.). 
Single  jerks  of  the  limbs  on  falling  asleep.  Troublesome  dreams 
of  one  and  the  same  thing,  all  night.     Palpitation  of  the  heari 

Lachesis. — Great  mental  and  physical  exhaustion.  Sleepi- 
ness, but  unable  to  sleep.  Sleep,  followed  by  aggravation  of  all 
the  symptoms.  Stupor  and  muttering  {apis).  Loquacious, 
constantly  changing  from  one  subject  to  another.  Thinks  she  is 
dead.  Sunken  countenance.  Dropping  of  the  lower  jaw  {lycop., 
opium).  Tongue  dry,  red  or  black,  cracked  and  bleeding  {ars. ). 
It  trembles  when  protruding  it  {gels.,  bell).  Inputting  out  the 
tongue  it  catches  on  the  teeth  or  under  lip.  Lips  dry,  cracked 
and  bleeding.  Appetite  variable.  Desire  for  oysters  {lye.). 
Hypersesthesia  of  the  abdomen.  Offensive  stools.  Intestinal 
hemorrhage  containing  flakes  and  granules  of  decomposed  blood. 
Dyspncea.  Hawking  of  mucus  with  rawness  in  the  throat. 
Superficial  ulcers  {mere.,  nit.  acid)  of  a  blackish-blue  appear- 
Falling  off  of  the  hair  {mere,  nit.  acid.,  phos.).  In  the 
spring. 

Lanrocerasus. — Irregular  beating  of  the  heart  with  slow 
pulse  {digit.).  Clonic  spasms  of  the  extremities  {canth.).  Want 
of  energy  of  the  vital  powers,  and  want  of  reaction. 

Lycopodium. — Depression  of  spirits  {nat.  puis.).  Great  fear 
of  being  left  alone.  Uses  wrong  words  to  express  an  idea 
{arnica,  anacardium,  graph.).  Restless  sleep.  Subsultus  ten- 
dinum. Earthy  color  of  the  face.  Circumscribed  redness  of  the 
cheeks.  Face  suddenly  yellow  or  pale  after  the  first  week  (gen- 
erally fatal).     Putrid  smell  from  the  mouth.     Tongue  coated 


184 


LECTURES   ON  FEVERS. 


white,  or  else  red  aud  dry.  ^  Vesicles  on  the  tongue.  "When  the 
tongue  is  spasmodically  thrust  to  and  fro  between  the  teeth. 
The  lower  jaw  drops  (apium,  mur.  acid.,  Inch. ).  Fan-like  motion 
of  the  alee  nasi.  Desire  for  sweet  things.  A  little  food  seems 
to  fill  the  stomach  full,  and  causes  fullness  and  diBtentii>n  of  the 
abdomen.  Bowels  much  distended  with  rumbling  in  the  left 
hypochondrium.  Chilliness  in  the  rectum  before  stool.  Urine 
leaves  a  red,  sandy  stain  on  the  sheet  {cinch.,  phos.).  Shortness 
of  breath.  Cough  with  scanty,  gray,  salty  expectoration.  Cold- 
ness of  the  hands  and  feet.  One  foot  hot  and  the  other  cold. 
Falling  out  of  the  hair  ( graph.,  ynerc. ,  pho». ).  The  hair  becomes 
gray  early.     Nervous  debility.     Ema'  iation. 

Morcurlujii. — Heaviness  of  the  head  with  great  inclination  to 
sleep.  Answers  questions  slowly.  Great  weariness  and  pros- 
tration. Trembling.  Pale,  earthy-colored,  puffy  face  {ars., 
2mls.).  Eyes  dull.  Tongue  swollen,  soft  and  flabby,  taking  im- 
pressions of  the  teeth  on  its  edges.  Putrid  odor  from  the  mouth, 
liegion  of  the  liver  painful  and  sensitive  to  contact  {hell,  hry.). 
Yellow-green  stools.  Bilious,  slimy  or  watery  diarrhea.  Abdo- 
men hard,  distended  and  painful.  Inguinal  glands  swollen  or 
suppurating  {nit  (wid).  Frequent  urination.  Urine  leaves  a 
whitish  sediment.  Clammy  perspiration  at  night.  Icteroid  hue 
of  the  skin.     Nose-bleed  during  sleep.     Sudamina. 

Muriatic  acid. — When  decomposition  of  the  fluids  is  slow  and 
extensive.  Continuous  delirium.  Vivid  hallucinations.  The 
patient  is  busied  with  past  and  present  events.  Forgetful  of 
time  and  place.  Irritable.  Sleepiness  in  the  daytime,  sleep- 
lessness at  night  with  muttering  delirium.  Constant  inclination 
to  slide  down  in  bed.  Photophobia.  Glistening  eyes,  con- 
tracted pupils.  Over-sensitive  to  sounds.  Acuteness  of  taste 
and  smell.  Excessive  dryness  of  the  lips,  mouth  and  tongue. 
Tongue  heavy,  like  lead,  preventing  talking.  The  lower  jaw 
hangs  down.  Great  thirst.  Watery  diarrhea  mixed  with  lumps 
of  whitish  mucus.  Involuntary  stools  while  urinating.  Profuse 
discharge  of  clear  pcid  urine.  Pulse  rapid  and  very  feeble,  in- 
termits every  third  beat  (fourth  beat,  nii.  acid).^  Kespiratious 
accelerated.  Excessive  prostratio^.  Painless,  rapidly  spread- 
ing, indolent  bed-sores.     In  low  fevers. 

Nitric  acid.— Irritable  and  excitable.    Anxiety  with  fear  of 


sstanaa 


LEADINO   INDICATIONH. 


196 


WJipn  tho 
n  the  teeth, 
n-like  motion 
food  eeoins 
;ontion  of  tlie 
ig  in  the  left 
stool.  Urine 
Shortness 
•ation.  Cold- 
le  other  cold, 
hair  becomes 

inclination  to 
)SB  and  pros- 
'  face  {ars., 
)y,  taking  im- 
m  the  mouth. 
t  {bell,  hnj.). 
rhea.  Abdo- 
is  swollen  or 
rine  leaves  a 
Icteroid  hue 

Is  is  slow  and 
lations.    The 

Forgetful  of 
ytime,  sleep- 
ot  inclination 
g  eyes,  con- 
less  of  taste 

and  tongue, 
le  lower  jaw 
i  with  lumps 
ag.  Profuse 
ry  feeble,  in- 
Bespiratious 
idly  spread- 

with  fear  of 


dentil  (ara.).  Froquent  pains  in  nil  parts  of  the  l)o<ly,  Kuddnnly 
appearing  nnd  diuappenring.  Pale,  yellowish  complexion. 
Putrid  smell  from  the  aiouth  {mere.).  Appetite  for  chnlk,  lime 
nnd  enrtJi  {(ilumhia).  AVhite  i-onting  on  tho  ttmgue.  Ulcers  in 
tho  mouth  nnd  fauces.  Accumulntion  of  mucus  in  the  throat. 
Great  sensitiveness  and  distention  of  tlie  abdomen.  Intestinal 
hemorrhnge.  Green,  slimy,  acrid,  fetid  ovncuatif)im.  Battling 
cough  with  purxilont  expectoration.  Brownish,  bloody  sputa. 
Pidse  irregular,  intermits  every  fourth  bent  (third  beat,  mur. 
acid).  Ulcers  with  stinging,  pricking  pnins  as  from  splinters. 
Emaciation,  especially  of  tho  arms  nnd  thighs.  Profuse  fnlling 
off  of  the  hair  {graph.,  nut.  mur.,  phus.).  After  tlie  abuse  of 
mercury. 

Nlix  moschata. — Fitful  mood.  Loss  of  memory  {anac.,pho8. 
acid).  Difficult  comprehension  {am.  curb.).  Great  drowsiness. 
Dryness  of  the  mouth,  tongue,  and  lips,  with  taste  as  after  eat- 
ing strongly  salted  food.  Little  or  no  thirst.  Boiling,  rum- 
bling or  gurgling  in  the  abdomen  {ahxis).  Colic,  n^lieved  by  hot 
wet  cloths.  Thin,  yellow  diarrhea  like  stirred  eggs.  Offensive 
colliquative  diarrhea.  Biunll,  slow  pulse.  Great  hmcnor  nnd 
excessive  miisoular  restlessness. 

Nux  vomica. — Over-sensitiveness  to  external  impressions 
{cinch.).  Delirious  phantasies  on  lying  down.  Chilliness  on 
slight  movement  Dryness  of  the  mouth  and  tip  of  the  tongue. 
Flatulent  distention  of  the  abdomen  after  eating  {cinch.,  lycop.). 
Desire  for  fat  food.  Hunger  with  aversion  to  food  {opium). 
Alternate  constipation  and  diarrhea.  Intestinal  cramps.  Great 
desire  to  sit  or  lie  down.     Emaciation.     Chlorosis. 

Opium. — Drowsiness  or  sopor.  Complete  loss  of  conscious- 
ness {hyoa.)  with  slow  stertorous  breathing.  Stupid  sleepless- 
ness with  frightful  visions.  Suffocating  nightmare.  Muttering 
delirium.  Attempts  to  escape  {bell,  hyos.).  Contracted  pupils 
hyos. ).  Glassy,  half -closed  eyes.  Face,  dark  red,  bloated,  hot 
{bell),  flushed  {hyos.),  or  pale  and  sunken.  Bed  feels  hot,  can 
hardly  lie  on  it.  Violent  thirst.  Irregular  respirations.  Deep 
snoring,  slow,  breathing  with  mouth  wide  open.  Convulsive 
movements  and  numbness  of  the  limbs.  Involuntary,  offensive 
stools  {ars.).  Dark,  fluid,  frothy  evacuations.  Violent  griping, 
cutting  pain  in  the  abdomen.    Betention  of  urine.    Dropping 


IfiO 


LKCTUnEH   ON   FEVEBH. 


of  tliC)  luwor  lip  Hiitl  jdw  {idt'li. 
Coid)i»^.:u  of  the  t  xtremitie«. 


mur.  acid).     Profuse  Hwer.t. 


PliosphorilH.— CouHtiuitnleepinosH.     Low,  muttering  delirium 
{am.,   hii})t.,   rlnis).      (Vjiuh     vigil.      Inability   to  coiu-eutrnte 
thought   {(ini.,  vIiuh).     Ciirpho'.;>gia    (cirn.,  Iiij(M.).     Contracted 
pupils  {opium,  jihiiHoxfiijma).      Palo,  Hallow  or  ehangciiiil -i  color 
of  the  face.     Dry,  immovable  timgue,  cracked  ami  coveiiu  wiM: 
8ord(!b  ( .'^«.,  vrrat  alb. ;.  ThirHt,  with  deBire  for  very  cold  drinkH. 
Burning r :  > he  stomach  {ars. ).     Regurgitation  ■  f  food  in  mouth- 
fuls.     Drir.!;!'?;;  caiises  rolling  and  rumbling  n\  the  abdomen. 
SeuHation  of  y  jukjje-*  and  omptinetts  in  tbr)  abdomen  (sepia). 
Vomiting  of  watery,  bilious  and  slimy  mabBes  with  great  pain 
in  the  first  and  at  the  beginning  of  the  second  week,  relieved  for 
a  time  by  ice,  or  very  cold  foo«l  or  drink.     Painless  diarrhea,  with 
abdominal  distention  and    loud  rumbling   {cinch.).      Watery, 
greenish,  sago-like,  or  bloody  evacuations,  worse  afit  ?   eating. 
Typhoid  pneumonia.     Hard,  dry  cough  witli  violent  oppression 
of  the  chest,  and  difScvtlf:  respiratioi..     Difficult  expectoration  of 
tenacious  mucus,  or  of  riiucus  streaked  •  v  ith  blood.     (3ough  worse 
from  evening  to  midnij^ht  {carlo  vrg.,  p/>!^.),  and  when  talking 
{(Iros.).     Loud  mucous  rale^  in  the  lower  lobes  (/j>ecac, /or/. 
emet).    Hepatization  of  th«j  lungs.     Small,  quick,  easily  com- 
pressed pulse.     Dullness  of  hearing,  especially  of  the  human 
voice.     Profuse  epistaxis.     Eose  spots  and  ecchymoses.     Great 
emaciation.     Weakness  in  the  extremities,  as  if  paralyzed. 

Phosphoric  acid. — Indifferent.  Disinclination  to  talk  {phos. 
opp.  s/raw.).  Incapacity  for  thought  {gels.).  Answers  ques- 
tions slowly  and  reluctantly,  or  short  and  incorrectly  {phos.) 
Somnolency  with  muttering  delirium.  Pale,  sickly  complexion. 
The  eyes  are  either  dim  or  glossy.  Hemorrhage  from  the  noso 
of  dark  blood  {ham.).  Intolerance  of  musical  sounds  {catist) 
Deafness  with  roaring  in  the  ears.  Dryness  of  the  mouth  and 
throat  without  thirst  {mix).  Grayish  coating  on  the  tongue. 
Desire  for  juicy  things  {puis. ).  Pressure  in  the  stomach  after 
eating.  Meteoristio  distention  of  the  abdomen  with  rumbling 
and  gurgling.  Involuntary  stools.  Thin,  whitish-gray  evacua- 
tions. Dry,  tickling  cough.  Frequent  emission  of  pale,  watery 
urine,  forj^ing  a  milky-white  cloud,  especially  at  night.  Fre- 
quent, small,  feeble  pulse.     Drj-,  clammy  skin.     Bluish-red  spots 


i. 


Prof  use  Hwer.t. 


tering  doliriuin 
to  concentrate 
).  Coiitracted 
langetif  il"i  color 
nl  coveii'l  wiM: 
sry  cold  ilrinkn. 

food  in  mouth- 
1  the  abdomen, 
ilomen  (sepia). 
vith  great  pain 
jek,  relieved  for 
8  diarrhea,  with 
ich.).  Watery, 
le  aflt  ■"  eating, 
lent  oppression 
ixpectoration  of 
(lough  worse 
id  when  talking 
>8  {ipecac,  iati. 
ick,  easily  com- 

of  the  human 
ymoses.  Great 
paralyzed. 

>n  to  talk  {phos. 

Answers  ques- 
orrectly  {phos.) 
kly  complexion, 
e  from  the  nose> 
sounds  {caust) 

the  mouth  and 
on  the  tongue, 
le  stomach  after 
.  with  rumbling 
sh-gray  evacua- 
.  of  pale,  watery 
nt  night.  Fre- 
Bluish-red  spots 


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LEADING   INDICATIONS. 


187 


on  the  parts  upon  which  the  patient  lies.     Profuse  uight  and 
morning  sweat  In  young  persons  who  have  grown  very  rapidly. 

Psorinum. — Loss  of  memory  during  convalescence.  De- 
spairing, melancholic  mood  {nux).  Deep-seated,  heavy  pain  in 
the  region  of  the  liver.  Dark,  brown,  fetid  stools.  Cough  with 
difficult  green  mucous  expectoration.  Great  debility  (sM(/)/t.). 
Profuse  perspiration  from  the  least  exertion,  and  at  night  {cinch., 
phos. ). 

Pulsatilla. — Peevishness,  or  inclination  to  weep.  Dullness 
with  pressive  pain  in  the  forehead.  Bestless  sleep  with  sensa- 
tions of  heat.  Chilliness.  Yivid,  frightful,  anxious  dreams. 
Offensive  odor  from  the  mouth.  Dryness  of  the  tongue,  ns  if 
burnt,  without  thirst  {may.  mur.).  Tenacious  mucus  in  the 
mouth.  Constant  spitting.  Bitter  taste  (6ry.).  Distress  in  the 
stomach  an  hour  after  eating  {nux.).  Pulsation  in  the  epigas- 
trium. Gnawing  in  the  stomach  as  from  hunger.  Loud  and 
painful  rumbling  and  gurgling,  especially  at  night.  Emission 
of  fetid  flatus.  Watery  diarrhea,  preceded  by  rumbling,  worse 
at  night.  Great  weariness  and  prostration.  Wandering  pains 
{kalibich.). 

Rhus  tox. — Great  restlessness  and  uneasiness  (rtrs. ).  Con- 
fusion and  dullness,  with  vertigo.  Incoherent  muttering.  An- 
swers questions  correctly  but  slowly  {hry.,  hepar.).  Active  de- 
lirium and  great  prostration.  Vivid,  troublesome  dreams  of  ex- 
cessive bodily  exertion.  Headache,  worse  from  opening  and 
moving  the  eyes  {puis.).  Pale,  sunken  face  with  blue  rings 
around  the  eyes.  Dark,  livid  redness  of  the  cheeks.  Epistaxis, 
morning  or  night.  Dry,  red,  cracked  tongue  {hapt,  bell.).  Bed- 
ness  of  the  tip  of  the  tongue  in  the  shape  of  a  triangle.  Putrid 
taste  and  breath.  Induration  of  the  parotid  and  sub-maxillary 
glands.  Sordes.  Great  thirst  for  cold  drinks,  especially  cold 
milk.  Nausea.  Copious,  thin,  yellow  e>-acuations,  worse  at 
night.  Involuntary,  fetid  stools,  during  sleep.  Dry,  tickling 
cough,  worse  in  the  evening  and  before  midnight.  Infiltration 
of  the  lower  lobes  of  the  lungs.  Severe  cough  with  tough, 
bloody  expectoration.  Soreness  as  if  beaten  in  the  hypochon- 
dria. Aching  pains  in  all  the  limbs;  must  constantly  change 
position. 

Secale  corn. — Constant  sighing.    Hiccough  {ar,^.,  nux  nios.)^ 


m 


n 


188 


LECTURES  ON  FEVERS. 


Is 


Great  prostration  and  extreme  restlessness.  Aversion  to  being 
covered.  Anxiety  and  burning  at  the  pit  of  the  stomach  {ars.). 
Fear  of  death.  Cold  perspiration  on  the  face  and  forehead. 
Sweat  from  the  head  to  the  epigastrium.  Face,  pale  and  sunken. 
Unquenchable  thirst.  Desire  for  sour  drinks,  especially  lemon- 
ade. Painless,  muco-bilious  vomiting,  with  great  prostration. 
Ravenous  hunger.  Thin,  olive-green  stools.  Involuntary  evac- 
uations. Suppression  of  urine.  Great  trembling  when  at- 
tempting to  move.  Fuzzy  feeling  in  the  extremities.  Cold,  blue, 
shrivelled  skin.     Extensive  ecchymoses.     Bed-sores. 

8ilicea. — Disposition  to  boils.  Periostitis  of  the  sacrum. 
Ulcers  with  stinging,  sticking,  burning  pains  ( ars.,  loch. ).  Weak- 
ness and  sense  of  great  debility.  Perspiration  on  the  slightest 
exertion  (septa).  Sensitive  to  cold  air,  takes  cold  easily.  Ema- 
ciation. 

Stramonium. — Stupid  indifference  (phos.  acid).  Loquacious 
delirium  {lack.,  lachnanihes).  Furious  delirium,  worse  from 
looking  at  shining  objects.  Tries  to  escape,  struggles  to  get  out 
■of  bed  {hell.,  rhus).  Wide  open,  staring  eyes  {hell.,  hyos.). 
Transient  loss  of  sight,  hearing  and  speech.  Oblique  vision. 
Dryness  of  the  throat.  Violent  thirst,  especially  for  sour  drinks 
{hry.,  secale).  Yellowish-brown  coaling  on  the  tongue  which  is 
dry  in  the  center  {hapt).  All  food  tastes  like  straw  (sulph.). 
Black  stools  which  smell  like  carrion  {ars.,  carho  veg.).  Hard, 
tympanitic  abdomen.  Suppression  of  urine.  Involuntary  urina- 
tion. Constant  restlessness,  with  jerking  motions  of  the  limbs 
and  of  the  whole  body.     Carphologia.     Subsultus  tendinum. 

Sulphur. — Anxiety  in  the  evening,  with  inability  to  sleep  at 
night.  Weakness  of  memory,  particularly  for  names.  Heat, 
fullness  and  pressure  in  the  forehead.  Hardness  of  hearing 
{caust).  Weakness  of  the  chest  when  talking  {2ihos.,  start.). 
Dyspnoea.  Short,  dry,  nocturnal  cough.  Anorexia  or  else 
ravenous  hunger,  particularly  about  10  or  11  A.  M.  Stomach 
feels  distended  after  eating  only  a  little  ( lye  ).  The  abdomen 
is  painfully  sensitive  to  the  touch  {hell).  Morning  diarrhea 
with  great  prostration.     Offensive,  turbid  urine  ( loch. ). 

Sulphuric  acid. — Irascibility.  Hardness  of  hearing  {calc., 
carh.,  sulph. ).  Deathly  paleness  of  the  face.  Dry,  red  or  brown 
tongue.     Aphthae.     Swelling  and  inflammation  of  the  sub-max- 


n  to  being 
ach  (ars.). 

forehead, 
ad  Bunken. 
Uy  Ic-mon- 
rostration. 
atary  evac- 

when  at- 
Cold,  blue, 


e  sacrum. 
).  Weak- 
e  slightest 
nly.   Ema- 

loquacious 
rorse  from 
i  to  get  out 
dl,  hyos.). 
jue  vision, 
lour  drinks 
ae  which  is 
V  (sulph.). 
h ).  Hard, 
itaryurina- 
:  the  limbs 
idinum. 

to  sleep  at 
les.  Heat, 
of  hearing 
hos.,  stan.). 
ia  or  else 
Stomach 
)  abdomen 
g  diarrhea 
)• 

ing  {calc., 
1  or  brown 
i  sub-max- 


LEADINO  INDICATIONS. 


18(> 


illary  glands.  Violent  hiccough.  Dar's,  persistent  heraon-hages. 
Blue,  ecchymotic  spots  (carho  vcg.,  mix  mos.,  j>/<o«.  acid). 
Shortness  of  breath.     Great  weakness  and  prostration. 

Tartar  emet. — Irresistible  inclination  to  sleep.  Trembling 
of  the  whole  l)ody.  Pule,  sunken  face.  White  pasty  coating  on 
the  tongue.  Tongue  red  in  streaks  and  dry  in  the  middle  ( rhus). 
Continuous  anxious  nausea.  Violent  and  painful  urging  to 
urinate  with  scanty  or  bloody  discharge  {can.  sat).  Great  rat- 
ling of  mucus  in  the  chest  {ijjecac).  Threatened  oedema  of  the 
lungs  {moschus). 

Terebinthina. — Stupefaction.  Coma  (opium).  Excessive 
prostration.  Dry,  smooth,  glossy  tongue.  Tympanites.  Fetid 
stools.  Intestinal  hemorrhage.  Quick,  small,  thready,  almost 
imperceptible  pulse.  Occasional  subsultus  tendinum.  The 
urine  is  scanty  and  has  the  odor  of  violets. 

Yeratrum  alb. — Sudden  sinking  of  strength.  Hippocratic 
countenance.  Cold  perspiration,  especially  on  the  forehead. 
Sunken  eyes.  Pointed  nose.  Tongue  cold  {carho  veg.),  or 
coated  white  with  red  tip  and  edges.  Violent  thirst  for  cold 
water  {ars., phos.).  Excessive  hunger  for  fruits,  acids  or  salt 
things.  Violent  vomiting  and  watery  diarrhea.  Oppressive  and 
spasmodic  contractions  of  the  chest.  Cold  breath.  Suppression 
of  urine.  Icy  coldness  of  the  hands  and  feet.  Continued  pro- 
found sleep.     The  patient  remembers  events  only  as  dreams. 

Veratrum  vir. — Muttering  delirium.  Restless  sleep,  with 
dreams  of  being  drowned.  The  eyes  remain  open  and  the  pupils 
are  dilated.  The  face  is  flushed  or  else  pale  and  covered  with 
cold  perspiration.  The  tongue  is  coated  white  or  yellow,  with  a 
red  streak  down  the  center.  The  pulse  is  irregular,  hard  and 
frequent,  and  the  heart  beats  rapidly  when  turning  over  in  bed 
{hell).  Oppression  of  the  chest,  with  slow,  labored  breathing. 
Dark,  turbid,  fetid  urine.  Involuntary  micturition.  Hiccough. 
Subsultus  tendinum.     Carphologia. 

Zincum. — Weakness  of  memory  {anac).  Unconsciousness. 
Brain  exhaustion.  Delirium  with  attempts  to  get  out  of  bed 
{hyos. ).  Constant  jerking  of  the  whole  body  during  sleep.  Car- 
phologia. Subsultus  tendinum.  Sliding  down  in  bed  {mur,. 
add).    Involuntary  evacuations.    Bed-sores. 


HMMMMMMHtt*!!'' 


190 


LECTURES  ON  FEVERS. 


HYGIENIC  AND  DIETETIC  TREATMENT. 

Ill  the  treatment  of  typhoid  fever  it  is  highly  important  that 
the  patient  be  properly  liygiened  and  fed. 

As  soon  ns  the  disease  is  suspected  the  patient  should  be 
ordered  to  bed,  and  not  permitted  to  leave  it  until  some  days 
after  complete  convalescence.  Absolute  mental  and  bodily  rest 
is  a  primary  necessity.  And  in  every  case  the  use  of  the  urinal 
and  bed-pan  to  receive  the  evacuations  from  the  bladder  and 
bowels  should  be  rigidly  insisted  upon.  The  sick-room  should 
be  large  and  well  ventilated,  and  situated  as  remote  as  possible 
from  the  original  source  of  infection.  The  temperature  of  the 
room  must  be  kept  below  60°  Fahr.  All  superfluous  articles  of 
furniture  should  be  removed  from  the  apartment.  The  patient 
should  lie  on  a  mattress — never  on  a  feather  bed — with  a  linen 
sheet  and  a  woolen  blanket  as  a  covering.  The  bed  and  body 
linen  should  be  changed  daily,  and  immediately  thrown  into  a 
vessel  containing  a  solution  of  carbolic  acid,  before  being  re- 
moved from  the  room.  The  bed  and  room  should  be  sprinkled 
with  Piatt's  chlorides,  and  the  water-closet  must  be  frequently 
disinfected.  The  room  should  be  kept  perfectly  quiet.  Visita- 
tions must  not  on  any  account  be  indulged  in  during  the  course 
of  the  fever,  and  to  but  a  limited  extent  during  the  early  days 
of  convalescence.  The  position  of  the  body  should  be  frequently 
changed,  and  when  sordes  collect  upon  the  teeth  they  may  be  re- 
moved by  the  use  of  a  soft  wet  towel.  Pieces  of  ice  allowed  to 
dissolve  in  the  mouth  will  to  some  extent  limit  the  formation  of 
sordes. 

Tympanites  is  constantly  present  in  typhoid  fever,  but  if  at 
any  time  it  becomes  great,  and  the  accumulation  of  flatus  in  the 
colon  is  excessive,  it  may  be  necessary  to  carefully  introduce  into 
the  bowel  an  intestinal  tube  to  remove  part  of  the  accumulated 
gas.  When  intestinal  hemorrhage  occurs  an  ice  bag  filled 
with  broken  ice  may  be  applied  to  the  abdomen.  The  food  at 
such  times  should  be  limited  to  meat  essence,  wine- whey  or 
koumysB,  and  must  be  taken  ice  cold.  Meat  essence  is  prepared 
by  cutting  a  pound  of  fresh  lean  b^^ef  into  small  pieces,  and  put- 
ting it  into  a  pint  bottle  without  water.  It  is  then  corked  loosely, 
and  the  bottle  immersed  to  its  neck  in  cold  water  in  a  stewpan. 
Bring  the  water  to  a  boil,  and  let  it  boil  for  two  hours.  Then 
pour  off  the  essence  without  filtering.  When  there  is  great  abdom- 


tfnin  J  WMiiiiMitiiiitirtW 


mm«ifSm»y'i>>tvffm»'^"' 


HYGIENIC  TREATMENT. 


191 


srtant  that 

should  be 
Bomu  clays 

jodily  rest 

ihe  uriiml 

adder  and 
om  should 
18  possible 
;ureof  the 

articles  of 
'he  patient 
ith  a  linen 

and  body 
own  into  n 

being  re- 
5  sprinkled 
frequently 
>t  Visita- 
'the  course 
early  days 
frequently 
may  be  re- 
allowed  to 
rmation  of 

r,but  if  at 
atus  in  the 
•oduce  into 
cumulated 
bag  filled 
'he  food  at 
e-whey  or 
3  prepared 
i,  and  put- 
ed  loosely, 
a  stewpan. 
rs.  Then 
tat  abdom- 


inal tenderness,  thinly  spread  mush  ur  iiax-seed  poultices,  well 
smeared  with  lanl,  are  exceedingly  grateful.  When  intestinal 
I)erf(jration  occurs,  opium  should  be  administered  in  addition  to 
tlie  indicated  remedy,  and  in  doses  sufficient  to  secure  absence 
of  intestinal  motion  for  several  days.  The  hypogastrium  must 
be  examined  by  palpation  and  percussion  twice  daily,  and  the 
catheter  used  when  necessary.  In  long  protracted  cases,  bed- 
sores are  to  be  prevented  by  frequent  changes  of  position,  by  the 
removal  of  pressure  by  means  of  cold  water  bags  or  air  cushions, 
and  by  bathing  the  parts  with  whisky  and  arnica.  Points  of 
pressure  may  also  be  protected  by  a  piece  of  kid  spread  smoothly 
with  soap  plaster.  When  erosions  appear,  the  parts  should  be 
washed  with  a  weak  solution  of  carbolic  acid,  and  afterwards 
dressed  with  lint  covered  with  the  glycerole  of  calendula,  or  with 
equal  parts  of  copaiba  and  castor  oil. 

The  cold  bath,  first  recommended  by  James  Currie,  of  Liver- 
pool, England,  in  1797,  but  which  had  fallen  into  disuse,  was  re- 
vived by  Brand  in  1868,  and  is  now  quite  extensively  used  in 
Europe.  It  has  not,  however,  been  very  generally  practiced  in 
this  country,  and  it  is  not  probable  that  it  will  be  accepted  in 
the  immediate  future  as  a  geiuaral  method  of  treatment  of  typhoid 
fever.  Mild  cases  do  not  require  it,  and  in  advanced  cases  it  is 
not  safe.  It  should  never  be  used  after  the  second  week  of  the 
fever.  And  as  a  general  rule,  if  after  using  from  four  to  eighv; 
baths  in  the  course  of  twenty-four  hours,  the  fever  rises  to  the 
same  or  a  higher  degree  than  before  using  the  bath,  little  or  no 
benefit  will  accrue  from  a  continuance. 

Loomis  gives  the  following  general  rules  for  using  Ziemssen's 
gradual  method  of  bathing:  As  soon  as  the  axillary  tempera- 
ture in  the  evening  rises  above  103°  Fahr.,  place  the  patient  in  a 
water-bath  having  a  temperature  of  70°  Fahr.  or  80°  Fahr.,  and 
gradually  lower  that  temperature  by  the  addition  of  cold  water 
or  ice,  until  the  temperature  of  the  patient  begins  to  fall.  It 
may  be  necessary  to  lower  the  temperature  of  the  bath  to  60° 
Fahr.  before  the  temperature  of  the  patient  is  affected;  but  the 
lowering  of  the  body  temperature  must  be  accomplished  by  the 
lowering  of  the  temperature  of  the  bath,  care  being  taken  that 
the  latter  does  not  fall  below  60®  Fahr.  When  the  temperature 
begins  to  fall,  the  thermometrical  observations  must  be  renewed 
every  two  or  three  minutes.    While  the  baths  are  being  used, 


I  -i 


I-* 


192 


LECTUHES  ON  FEVEll.> 


the  temperature  must  be  taken  by  placing  the  thermometer  in  the 
rectum.  If  it  falls  rapidly — that  is,  two  or  three  degrees  in  five  or 
six  minutes — as  soon  as  the  fall  has  reached  103°  Fahr.,  remove 
your  patient  from  the  bath;  if  it  falls  slowly,  as  soon  as  it  reaches 
101'^  Fahr.,  he  should  be  removed  and  immediately  pl.iced  in 
bed.  Never  keep  the  patient  in  the  bath  until  the  temperature 
shall  liave  reached  the  normal  standard;  for  this  may  cause  him 
to  pass  from  a  condition  of  fever  into  a  state  of  collapse,  as  the 
temperature  continues  to  fall  for  some  time  after  his  removal 
from  the  bath.  While  in  the  bath,  cold  should  be  applied  to  the 
head  by  means  of  a  sponge  wet  in  cold  water  or  by  an  ice  bag. 

The  cold  pack  is  much  less  effective  than  the  bath,  as  four 
packs  are  only  equivalent  to  one  cold  bath.  Frequent  sponging 
of  the  body  with  equal  parts  of  aromatic  vinegar  and  tepid  water, 
or  with  tepid  whisky  and  water,  will  allay  dryness  and  heat  of 
the  skin,  and  if  done  in  the  evening  will  promote  sleep. 

The  diet  should  be  nutritious,  liquid,  and  on  account  of  the 
enfeeblement  of  the  digestive  and  assimilative  powers,  easily 
digestible.  It  should  be  administered  in  small  quantities  and  at 
short  intervals.  The  best  beverage  is  fresh  water,  which  may  be 
given  often.  Milk  and  water,  koumyss  or  thin  barley  water  are 
grateful  drinks.  Fruits  should  be  prohibited;  and  solid  food 
must  not  be  given  until  the  temperature  has  remained  at  the 
normal  for  at  least  three  successive  days.  After  the  first  week 
as  much  food  should  be  given  as  can  be  properly  digested,  and 
when  there  is  extreme  prostration  it  should  be  administered 
every  half  hour  or  hour. 

Milk,  which  has  been  aptly  defined  as  fluid  flesh,  bone  and 
nerve,  leads  the  list  of  fever  foods.  It  is  the  best  diet  during 
the  stage  of  catarrhal  inflammation.  It  does  not,  however,  agree 
with  all  cases,  and  must  not  be  used  in  unlimited  quantities,  as 
it  sometimes  lies  in  curds  in  the  stomach  and  bowels.  In  order 
to  make  it  more  digestible  it  may  be  reduced  by  dilution  with  one- 
half  or  one-third  of  lime  water.  The  addition  of  two  or 
three  grains  of  pepsin  and  pancreatin  to  each  cupful  of  food 
proves  A  valuable  aid  to  digestion.  Usually  patients  will  take 
trom  four  to  six  quarts  of  milk  and  lime  water  per  day.  Meat 
broths  made  of  beef,  mutton,  veal  or  chicken,  and  containing  a 
little  barley  or  well  cooked  rice,  may  be  given.  The  addition  of 
claret  or  port  serves  to  make  the  broths  more  palatable.    Gen- 


DIETETIC  TREATMENT. 


193 


•meter  in  the 
•ees  in  five  or 
[ahr.,  remove 
as  it  readies 
}y  pLiced  in 
temperature 
ly  cause  him 
lapse,  as  the 
his  removal 
•plied  to  the 
m  ice  bag. 
>ath,  as  four 
ent  sponging 
tepid  water, 
and  heat  of 
3ep. 

count  of  the 
owers,  easily 
itities  and  at 
hich  may  be 
ey  water  ar» 
Id  solid  food 
lained  at  the 
he  first  week 
igested,  and 
idministered 

ih,  bone  and 
diet  during 
»^ever,  agree 
aantities,  as 
••    In  order 
>nwithone- 
of   two  or 
f ul  of  food 
;s  will  take 
iay.    Meat 
>ntaining  a 
addition  of 
We.    Gen- 


erally it  will  be  well  to  alternate  milk  with  the  broths,  every  two 
hourH  during  the  day,  and  every  throe  hours  during  the  night. 
Koumyss  or  fresh  buttermilk  often  proves  a  very  grateful 
change  to  patients  who  weary  of  milk,  and  may  be  given  as  a 
substitute  where  patients  will  not  drink  the  latter. 

Beef-tea,  which  is  claimed  by  some  practitioners  to  be  the 
proper  diet  for  typhoid  patients,  will  never  take  the  place  of 
milk.  To  prepare  it,*  chop  a  pound  of  lean  beef  into  very  small 
pieces,  j)our  over  it  about  a  pint  of  cold  water,  cover,  and  lot  it 
stand  two  hours  by  the  side  of  the  fire;  then  place  it  on  the 
fire  and  allow  it  to  boil  for  a  half  hour.  Afterwards  remove  the 
scum,  and  skim  off  all  the  fat;  salt  to  the  taste;  do  not  filter 
or  strain  it,  simply  pour  it  oflf.  If  rightly  made  it  should  have' 
a  rich  brown  appearance  when  stirred.  As  a  rule  more  patients 
dislike  than  like  it  The  place  of  usefulness  assigned  to  it  is 
after  the  middle  of  the  second  week,  and  yet  I  am  free  to  say  tliat 
you  will  be  often  disappointed  in  its  use.  When  administered 
indiscriminately  it  is  supposed  to  have  a  tendency  to  keep  up  the 
temperature. 

For  general  use  you  will  find  Leube's  Beef  Solutionf  the  best 
animal  diet  preparation,  as  it  is  highly  nutritious  and  is  more 
easily  digested  than  any  other  of  the  meat  extracts.  When- 
ever the  stomach  fails  to  retain  food  and  rejects  even  Leube's 
solution,  Valentine's  Meat  Juice  may  be  administered  hypo- 
dermatically  in  doses  of  from  one  to  two  fluid  drachms.  Meat- 
pancreas  injections,  so  useful  in  gastric  ulcer,  and  prepared 
by  adding  one  and  one-half  ounces  of  finely  chopped  pan- 
creas, and  five  ounces  of  finely  scraped  beef,  to  three  ounces  of 
lukewarm  water,  and  stirring  to  the  consistence  of  th^(  k  pulp, 
may  if  used  with  caution,  per  rectum,  be  of  benefit  i-.-  {."(--.tients 
who  are  very  low.  In  cases  of  extreme  prostration  the  intrave- 
nous injection  of  milk — prepared  by  adding  ten  grains  of  car- 
bonate of  ammonia  to  six  ounces  of  goat's  milk — has  been  used 
with  good  effect. 

Alcoholic  stimulants  are  unnecessary  and  injurious  up  to  the 
end  of  the  second  week,  and  many  cases  require  no  stimulation 

*  Johnstoa's  Fluid  Beef,  or  Scott  and  Bowne's  Soluble  Peptonized  Granu- 
lated Beef,  may  be  used. 

t  Prepared  by  Ph.  liudisch,  of  New  York. 


194 


LECTURES  ON  FEVERS. 


throughout  tlio  whole  course  of  the  attack.  The  iadications 
wliich  call  for  their  administration  are  mainly  such  as  are  de- 
pendent upon  the  weakness  of  the  heart's  action,  nnd  consist  of 
a  feeble  or  imperceptible  cardiac  impulse,  and  a  diminution  or 
early  subsidence  of  the  first  sound.  Stimulation  may  be  con- 
tinued, when,  under  its  use,  the  tongue  becomes  moist,  the  first 
sound  grows  more  distinct,  the  pulse  slower,  and  the  sound  clear; 
it  should  be  abandoned,  when,  under  its  administration,  the 
tongue  becomes  dry,  the  lieart's  action  becomes  more  rapid,  or 
the  brain  symptoms  deepen.  It  is  difficult  to  lay  down  rules  as 
to  the  quantity  of  wine  or  other  stimulants  to  be  exhibited;  every 
case  has  its  own  peculiarities.  At  first  half  a  wine-glassful  of 
wine-whey — prepared  by  adding  half  a  pint  of  sherry  to  one  pint 
of  boiling  milk,  and  straining  after  coagulation— may  be  given 
every  three  hours.  Later,  if  the  patient  grows  weaker,  half  an 
ounce  of  brandy  or  an  ounce  of  wine  may  be  given  with  the 
same  or  twice  as  much  milk,  every  two  to  four  hours,  especially 
at  night.  Whenever  the  urine  becomes  albuminous,  brandy  and 
whisky  must  be  used  with  the  greatest  caution.  Never  despair 
as  long  as  your  patient  can  swallow. 

During  convalescence,  if  stimulants  are  needed,  sherry  wine 
either  alone  or  as  wine-whey  is  the  most  eligible.  In  the  first 
week  of  convalescence,  the  diet  should  be  restricted  to  milk  cus- 
tards, and  farinaceous  foods  and  animal  broths.  Wine  of  pepsin 
taken  after  each  meal  materially  aids  digestion.  After  the  end 
of  a  week,  solid  food  may  be  gradually  resumed.  Milk  punch 
and  egg-nog  are  often  of  servica  If  diarrhea  is  present  dur- 
ing convalescence  it  is  safer  to  restrict  the  patient  to  milk  and 
cream.  All  exercise  other  than  simply  walking  around  the 
xoom  should  be  prohibited. 

When  convalescence  is  tardy  the  patient  will  be  greatly  bene- 
fited by  change  of  air  and  scenery.  A  short  residence  at  the  sea- 
shore usually  exerts  a  very  salutary  inftuence  in  promoting  an 
early  restoration  to  health.  Aitkin  utters  a  truism  when  he 
says  no  man  can  be  considered  fit  for  work  for  three  or  foor 
months  after  an  attack  of  severe  typhoid  fever. 


wmwimwiim-i*  immmuwiW'''^ 


le  iudicntionH 
bch  08  are  de- 
find  consist  of 
diraimition  or 
mil)'  be  con- 
Imoist,  the  first 
16  sound  clear; 
Inistration,  tlie 
I  more  rapid,  or 
doAvn  rules  as 
thibited;  every 
ine-glassful  of 
Jrry  to  one  pint 
may  be  given 
weaker,  half  on 
[given  with  the 
)urs,  especially 
)U8,  brandy  and 
'  Never  despair 

I,  sherry  wine 
|e.  In  the  first 
ted  to  milk  cus- 
Wine  of  pepsin 

After  the  end 
.  Milk  punch 
s  present  dur- 
t  to  milk  and 
ig  around  the 

>  greatly  bene- 
nee  at  the  sea- 
promoting  an 
lism  when  he 
three  or  f cur 


LECTURE  XIII. 

Yellow  Fever. 

"We  are  to-day  to  study  Yellow  Fever — the  second  in  the  list 
of  miasmatic-contagious  fevers. 

Definition. — It  may  be  defined  as  a  continued  fever  produced 
by  the  introduction  into  the  human  organism  of  a  specific  poison, 
and  consisting  of  a  single  paroxysm  of  indefinite  duration,  but 
always  tending  to  terminate  in  two  or  four  days,  or  a  multii)le 
thereof.  It  is  characterized  by  early  epigastric  tenderness, 
severe  nausea, projectile  vomiting;  fiery  eyes,  violent  supra-orbi- 
tal headache;  pains  in  the  back  and  calves  of  the  legs;  a  slow, 
uncertain,  easily  compressed  pulse;  a  deep  yellow  or  bronzed 
skin — after  the  third  day;  black  vomit — one  or  two  days  pre- 
Tious  to  death;  suppression  of  urine  and  albuminuria.  It  is  a 
}K)rtable  disease  and  has  an  average  duration  of  six  days.  One 
attack  afibrds  almost  certain  immunity  for  a  life-time.  After 
.  death  constant  lesions  of  the  liver,  kidneys,  blood,  skin,  and 
mucous  membrane  are  found. 

Synonyms. — It  has  been  variously  described  as:  Febris  flava. 
Febris  typhus  icterodes.  Febris  cum  nigro  vomito.  Fievre 
jaune;  and  Typhus  d'Amerique. 

History. — It  is  said  to  have  made  its  first  appearance  either 
in  the  West  Indies  or  in  Mexico  many  years  before  the  Spanish 
conquest  It  prevailed  in  Central  America  in  1596,  and  among 
the  Indians  of  New  England  as  early  as  1618.  It  visited  New 
York  for  the  first  time  in  1668,  Charleston  in  1682,  Boston  in 
1691,  Philadelphia  in  1695,  and  the  Gulf  Coast  in  1702.  It  made 
its  first  appearance  in  Europe,  at  Cadiz,  Spain,  in  1705.  Pensa- 
cola  received  its  first  visitation  in  1764,  and  New  Orleans  in  1796. 

(195) 


I 


"i 


V; 


I9r> 


LECTUnES  ON  FEVERS. 


The  epidemic  of  1804,  in  Spain,  wrh  nttended  by  tho  henviPBt 
niortftlity  on  record.  The  worst  epidemic  in  New  Orleans  wan 
in  1H53.  Memphis  was  first  visited  in  1855,  althoiigh  the  disease 
appeared  at  Ft.  Pickering,  now  a  sxiburb,  in  1828.  The  second 
visitation  was  in  1867.  A  very  destructive  epidemic  devastated 
the  city  in  1873,  and  in  1878  a  little  less  than  one-tliird  of  the 
totol  population  died.  In  1870  the  disease  was  very  destructive 
in  Barcelona,  Spain,  and  in  1871  at  Buenos  Ayres.  In  the  greot 
epidemic  of  1878  tho  mortality  record  of  New  Orleans — which 
stands  next  to  Memphis — is  estimated  at  4,600,  and  that  of  Vicks- 
burg  at  872.  In  this  epidemic  the  disease  extended  as  far  north 
as  St  Louis,  Mo.,  Cairo,  111.,  and  Qallipolis,  Ohio. 

Oeographical  Limits. — Yellow  fever  is  uncommon  in  elevated 
regions,  and  seldom  occurs  beyond  4,000  feet  above  the  level  of 
the  sea.  It  rarely  prevails  beyond  45°  north  latitude  and  23° 
south  latitude.  Epidemics  have  occurred  as  far  north  as  Quebec, 
Canada;  as  far  south  as  Montevideo,  Uruguay;  as  far  east  aa 
Madrid,  Spain;  and  as  far  west  as  Mexico.  The  conspicuoua 
zones  for  its  ravages  are:  Barbadoes,  West  Indies,  on  the  east; 
Tampico,  Mexico,  on  the  west;  Rio  de  Janeiro,  Brazil,  on  the 
south;  and  Charleston,  U.  8..  on  the  north. 

In  Europe  it  has  invaded  Spain,  Portugal,  Italy,  France  and 
England.  It  has  frequently  prevailed  along  the  western  coast 
of  Africa;  recently  in  the  province  of  Senegal.  In  South  Amer- 
ica it  has  prevailed  in  Venezuela,  Colombia,  Peru,  Bolivia, 
Buenos  Ayres,  and  Brazil.  In  North  America,  it  has  invaded 
Mexico,  the  West  Indies,  Canada,  and  all  the  States  of  the 
Union,  except  Wisconsin,  Michigan,  Iowa,  Minnesota,  Kansas, 
Nebraska,  California  Colorado,  Oregon,  Nevada,  and  the  Terri- 
tories, omitting  the  Indian  Territory.  It  often  visits  the  tropi- 
cal islands  of  the  Atlantic,  but  has  never  made  its  appearance 
among  the  islands  of  the  Pacific.  It  is  unknown  in  Asia,  Aus- 
tralia, the  East  Indies,  and  along  the  eastern  shores  of  Africa; 
and  has  only  been  felt  sporadically  along  the  Pacific  coast  of  the 
American  continent 

Yellow  fever  has  become  naturalized  in  Brazil,  the  West  In- 
dies, Venezuela,  New  Granada,  Mexico,  and  along  the  Gulf  and 
south  Atlantic  coasts  of  this  country  as  far  as  Charleston. 

Etiology. — The  nature  and  source  of  the  yellow  fever  poison 


1 


■MWHlHMiMmMi  WM 


ITIOLOOY. 


197 


ly  ihci  }ienviP8t 
Iw  OrloftiiH  WHS 
pgh  tlie  (lisense 
.    The  secoiul 
uic  devnHtftteil 
lie-third  of  the 
pry  tlestruotive 
III  the  great 
means— wliich 
1  that  of  Vicks- 
Btl  BH  far  north 

ion  in  elevated 
ve  the  level  of 
fcitude  and  23° 
)rth  as  Quebec, 
as  far  east  aa 
le  conspicuoua 
ss,  on  the  east; 
Brazil,  on  the 

ly,  France  and 
I  western  coast 
1  South  Amer- 
Peru,  Bolivia, 
t  has  invaded 
States  of  the 
esota,  Kansas, 
ind  theTerri- 
sits  the  tropi- 
ts  appearance 
in  Asia,  Aus- 
res  of  Africa; 
io  coast  of  the 

the  West  In- 
the  Gulf  and 
'leston. 

fever  poison 


are  OS  yet  enshrouded  in  uncertainty.  We  simply  know  that  it 
originatim  outside  of  the  organism,  that  it  can  \\e  reprcxlucetl 
only  when  the  atmosphere  lias  l)ecome  loaded  with  ttnuiiiatinns 
from  animal  and  vegetable  de(;om{K)sition,  that  it  is  ]M)rtable,  and 
that  it  can  be  conveyed  from  one  locality  tt)  another  by  means  of 
clothing,  merchandise,  and  more  particularly  in  the  holds  of 
vesHfils.  It  resembles  the  poison  of  typhoid  fever  in  that  it  can- 
not be  conveyed  directly  from  the  sick  to  the  healthy,  but  must 
tirstlie  deposited  in,  or  come  in  contact  with,  decomposing  organic 
matters.  Atmospheric  air  is  the  usual  medium  through  which 
the  infection  is  received  into  the  human  system. 

As  no  satisfactory  proof  of  the  de  novo  origin  of  yellow  fever 
can  be  found,  many  ingenious  and  at  times  absurd  theories  of 
causation  have  been  promulgated  by  physicians.  Dr.  Stone 
holds  to  the  wave  or  cycle  theory,  and  believes  that  the  epidemic 
influence  is  wafted  through  the  atmosphere  in  waves  or  cycles, 
in  gradual  and  regular  approaches.  Dr.  Stille  attributes  its 
•origin  in  this  country  to  the  Gulf  Stream.  Dr.  Ford  advocates 
the  theory  of  fermentation.  Dr.  Labadie  favors  the  explosive 
theory,  4)elieving  that  it  is  a  i>eculiar  subtle  poison  that  explodes 
in  the  air,  like  an  inflammable  substance.  But  the  majority  of 
physicians  hold  with  Dr.  Davidson  that  it  is  due  to  a  living  or- 
ganized mioroscopicentity,  which,  generated  out  of  pre-existing 
germs  under  favorable  circumstances,  propagates  itself  indef- 
initely ;  and,  as  Sternberg  suggests,  that  something  given 
off  from  the  body  of  the  sick,  after  a  time  and  with  the  concur- 
rence of  favorable  conditions,  becomes  or  produces  the  true 
poison  of  the  disease. 

The  meteorological  and  local  conditions  which  favor  its  evo- 
lution, and  which  seem  to  be  necessary  to  the  evolution  of  yel- 
low fever  epidemics  are: 

1.  A  continued  high  temperature. — Yellow  fever  never  spreads 
where  the  thermometer  stands  less  than  72°  Fahr.  The  average 
temperature  for  twenty-four  hours  must  be  above  77°  Fahr. 
Heat  may  be  considered  as  the  only  essential  in  the  causation  of 
ihe  disease. 

2.  Excess  of  moisture. — A  certain  amount  of  moistnre  either 
in  the  atmosphere  or  in  the  substance  of  the  soil  is  generally 
necessary  for  the  reproduction  of  the  germ.  Heavy  rains  fol- 
lowed by  a  very  high  temperature  favor  the  rapid  spread  of  yellow 


f 


198 


LECTUBES  ON  FEVERS. 


fever.  A  sufficient  amount  of  moisture  is,  in  this  country,  always 
present  in  the  atmosphere.  In  the  Southern  States,  the  clear  days 
of  the  season  of  the  disease  are  called  "  yellow  fever  weather." 

3.  Organic  matters  in  a  state  of  decomposition. — Decaying  ani- 
mal and  vegetable  matters  are  exceedingly  favorable  if  not  essen- 
tial to  the  reproduction  of  the  germ.  Bilge-water  in  the  holds 
of  sliips  may  be  the  medium  of  transportation  of  the  morbific 
agent  from  port  to  pert,  while  accumulated  filth,  especially 
city  garbage,  affords  a  rich  nidus  for  its  reproduction  and  dis- 
semination in  crowded  citiee. 

4  Nearness  to  a  tropical  sea,  or  to  a  large  river  emptying  inta 
such  sea. — Yellow  fever  is  almost  wholly  confined  to  level  dis- 
tricts in  large  river  and  sea-port  cities  of  warm  climates.  Th» 
germ  travels  three  times  as  fast  in  tropical  regions  as  it  does  in 
the  outer  limits  of  the  £ever  zone.  Its  average  rate  of  progress 
is  about  forty  feet  per  day. 

5.  A  deficiency  of  ozone  in  the  atmosphere. 

The  germs — (micrococci?) — of  yellow  fever  being  portable, 
may  be  conveyed  in  baggage  or  merchandise  (fomite%)  along^ 
the  routes  of  travel  from  infected  to  non-infected  districts.  Un- 
less so  conveyed,  as  their  progress  is  naturally  very  slow,  the  in- 
fection may  be  confined  to  a  single  block  or  district  of  a  city. 
(This  fact  alone  must  always  render  judicious  quarantine  of  vital 
importance).  They  are  commonly  most  active  near  the  surface 
of  the  earth,  and  at  night.  They  may  be  dormant  for  many  years 
consecutively,  only  requiring  a  concurrence  of  causes  to  arouse 
them  to  disease  producing  activity.  Few  germs  survive  a  tem- 
perature below  32°  Fahr.  and  all  perish  at  212°  Fahr. 

Epidemics  of  yellow  fever  are  self -limited  and  seldom  continue 
longer  than  from  sixty  to  seventy  days.  They  usually  appear  in 
this  country  in  July  or  August  and  disappear  upon  the  advent 
of  frost.  Malignant  intermittent  fevers  frequently  precede  out- 
breaks of  yellow  fever  epidemics.  South  and  easterly  winds 
favor  the  development  of  the  disease,  while  north  and  west  winds 
tend  to  arrest  it.  Negroes  are  most  exempt  from  its  attacks. 
Having  had  the  disease  is  a  partial  protection  against  a  recur- 
rence. A  prolonged  residence  in  a  yellow  fever  district  also 
renders  the  individual  less  susceptible.  This  diminished  sus- 
ceptibility will,  however,  last  only  while  the  individual  remains 


U 


mi-^jfijyr"*^'^''  '"'  ^ 


ETIOLOGY. 


199 


3  country,  always 
lies,  the  clear  days 
f  fever  weather." 

!. — Decaying  ani- 
able  if  not  essen- 
ater  in  the  holds 
I  of  the  morbific 
filth,  especially 
duction  and  dis- 

ver  empiying  inia 
ned  to  level  dis- 
1  climates.  Th& 
ions  as  it  does  in 
I  rate  of  progress 


being  portable,. 

(fomite%)  along 
3d  districts.  Un- 
very  slow,  the  in- 
iistrict  of  a  city, 
aarantine  of  vital 
I  near  the  surface 
at  for  many  years 

causes  to  arouse 
ns  survive  a  tem- 

Fahr. 

i  seldom  continue 
usually  appear  in 

upon  the  advent 
intly  precede  out- 
d  easterly  winds 
th  and  west  winds 

from  its  attacks. 
I  against  a  recur- 
3ver  district  also 

diminished  sus- 
idividual  remains 


^tanily  iu  th.  yeUow  fever  -J'- ^X-ttXtreS 

"Tiling  the  ^ueetion  o.  -t^^ori  rX:^^^™:^ 
stant  experience  of  yellow  i«^^^'  ,  ^  the  disease 

re:::sxt^rh:j;eT:etri^ineo,taet.u-,... 

She  id^  oJ  contagion  «  generally  receded. 

In  sumn.ing  np  the  etiology  of  yellow  few  we  amve  leph- 
mately  at  the  following  conolueions: 

1.  The  disease  is  prodneed  by  a  specific  germ. 

2  The  impression  on  the  organism  is  as  specflc  as  that  pro- 

^A^rf  ^:l    partial  protection   from    snhse,nent 
'TThe  white  population  of  s«^e  tempe^nent  snffer  most 

gation  of  germs.  ^^rsonallv  contagious,  becau^  of  the 

J„r  tr.  rtrrr;S,ciple  c^ontamea  m  the  e.h. 

' t -^hT^etfrnT^^'clteT^  «-  ^"^  *«  "'>-■"='** 
"t'C'^ri^'of^nenbation  o.  the  gem>  is  from  two  to  nine 

*  m  The  average  length  of  an  epKlemic  is  from  sixty  to  seventy 
days. 


HMMUiJuutuwm 


r 


200 


LECTURES  ON   FEVERS. 


Clinical  History. — The  clinical  history  embraces  n  descrip- 
tion of  the  prodromal  stage,  the  stage  of  initial  fever  or  the 
paroxysm  proper,  and  the  period  of  sequels  which  includes  the 
stages  of  calm  and  of  reactionary  fever. 

The  period  of  inciihation  of  yellow  fever — the  time  which 
elapses  between  the  absorption  of  the  poison  by  the  organism, 
and  the  appearance  of  the  first  signs  of  the  disease — varies  from 
a  few  hours  to  several  days  or  even  weeks.  Its  average  length 
is  from  one  to  two  or  three  days.  Prodromal  phenomena  simi- 
lar to  those  observed  in  other  infectious  diseases,  and  consisting 
of  a  general  feeling  of  uneasiness  or  discomfort,  headache,  pains 
in  the  limbs,  and  loss  of  appetite,  occasionally  precede  the  attack. 
Usually,  however,  the  onset  is  apparently  abrupt,  the  disease 
taking  the  patient  by  surprise,  either  in  the  morning,  while  en- 
gaged in  business,  or  during  sleep. 

The  paroxysm. — In  mbst  cases  the  ushering  in  symptom, 
which  marks  the  beginning  of  the  stage  of  initial  fever,  is  a  chilly 
feeling  along  the  spine  passing  into  actual  rigor.  Immediately 
the  patient  feels  seriously  ill,  complains  of  stinging  pains  in  the 
forehead  and  temples,  as  also  of  pains  in  the  back  and  limbs,  and 
more  especially  in  the  calves  of  the  legs.  Soon  the  sensation  of 
cold  alternates  with,  and  rapidly  gives  way  to  one  of  heat.  The 
patient  becomes  restless,  and  presents  an  appearance  of  alarm 
and  anxiety.  The  countenance  is  flushed,  the  conjunctiva  in- 
tensely congested,  and  the  eye  has  a  peculiar  muddy  appearance. 
The  tongue  is  covered  by  a  white  or  thin  yellowish  fur,  and  is 
scarlet  colored  at  the  tip  and  edges.  The  fauces  appear  bright 
red  and  oedematous.  The  skin  becomes  hot,  and  is  either  dry  or 
bathed  in  profuse  perspiration.  Frequently,  as  early  as  the 
second  day  it  emits  a  peculiar  cadaveric  odor.  The  temperature 
rises  rapidly  and  often  reaches  102"  Fahr.  or  104°  Fahr.  within 
a  few  hofirs  after  the  chill.  The  respiration  is  hurried  and  fre- 
quently irregular.  The  pulse  is  full  and  hard,  averaging  from 
one  hundred  to  one  hundred  and  ten  beats  per  minute.  The 
epigastrium  is  extremely  sensitive  to  pressure,  and  occasionally 
there  is  nausea  with  frequent  and  unsuccessful  attempts  at 
vomiting.  The  bowels  are  usually  constipated;  if  discharges 
occur  they  are  dark  colored  and  offensive.  On  the  second  day, 
in  those  exceptional  cases  which  assume  the  ephemeral  form, 
after  some  free  alvine  or  urinary  evacuations,  the  pulse  and  tem- 


H 


I!! 


f.rifiiiiiiiftmiVi 


CLINICAL   HISTORY. 


201 


laces  o  descrij)- 

|al  fever  or  tlie 

ch  includes  the 

|lie  time  which 
the  organism, 

le — varies  from 

average  length 
[lenomena  simi- 

and  consisting 
leadache,  pains 
cede  the  attack. 
[>t,  the  disease 
ning,  while  en- 

in  symptom, 
^erer,  isachilly 

Immediately 
ng  pains  in  the 
and  limbs,  and 
he  sensation  of 
I  of  heat.     The 
irance  of  alarm 
conjunctiva  in- 
Idy  appearance, 
rish  fur,  and  is 
i  appear  bright 
is  either  dry  or 
J  early  as  the 
lie  temperature 
°  Fahr.  within 
irried  and  fre- 
veraging  from 
minute.     The 
d  occasionally 
i  attempts  at 
if  discharges 
le  second  day, 
hcmeralform, 
ulse  and  tem- 


perature may  suddenly  fall,  the  fever  speedily  subside,  and  the 
patient  enter  upon  a  rapid  convalescence.  Such  a  course  is,  how- 
ever, by  no  means  common,  for  in  the  majority  of  instances  the 
febrile  movement  continues  to  the  third  or  fourth  day.  The 
temperature  then  usually  reaches  its  maximum  height  on  the 
evening  of  the  second,  which  in  this  country  rarely  exceeds  104° 
Fahr.  In  rare  cases  the  thermometer  has  been  known  to  regis- 
ter 105"  Fahr.  or  even  107"  Fahr.  The  pulse  generally  falls 
after  the  second  day,  with  a  progressively  increasing  rapidity, 
and  on  the  fourth  day  oscillates  toward  eighty.  The  mind  is 
usually  clear,  but  occasionally  delirium  makes  its  appearance  on 
the  second  day.  In  mild  cases  this  delirium  may  be  confined  to 
irrational  utterances,  while  in  severe  cases  it  may  become  so  vio- 
lifitas  to  render  physical  restraint  necessary.  In  fatal  cases 
lulirium  is  rarely  absent.  Usually  on  the  morning  of  the  third 
day,  but  frequently  not  before  the  fourth  or  fifth  day,  the  febrile 
storm  commences  to  subside.  After  some  free  evacuation  of  the 
bowels  or  bladder,  the  temperature  l^egius  to  fall,  and  the  pulse 
continues  its  steady  downward  course  begun  on  the  second  day. 
All  the  symptoms  abate  except  the  epigastric  tenderness.  The 
patient  sits  up  and  feels  better;  and  in  favorable  cases  convales- 
cence now  commences. 

The  stage  of  calm. — Much  more  often  the  defervescence  is  not 
complete,  the  temperature  does  not  fall  below  100°  Fahr.  and  the 
patient  has  simply  passed  into  that  deceptive  ^rs/penorf  of  se- 
quels— the  stage  of  calm.  The  duration  of  this  so-called  second 
stage  is  very  short,  rarely  exceeding  from  two  to  three  or  at  the 
utmost  twenty-four  hours.  Graver  symptoms  of  a  typhoid  char- 
acter now  appear,  and  the  patient  approaches  the  third  stage  of 
the  disease, — the  second  sequel — the  stage  of  reactionary  fever. 

The  stage  of  reactionary  fever. — The  temperature  which  had 
commenced  to  fall  rises  again  rapidly,  and  after  two  days  reaches 
104°  Fahr.  The  pulse  becomes  quick,  at  times  slow,  but  always 
small  and  thready.  The  stomach  becomes  more  imtable,  and 
rejects  all  food  and  drink.  The  conjunctiva  presents  a  yellow- 
ish appearance — sometimes  even  as  early  as  the  third  day.  The 
skin,  in  about  one-sixth  of  the  cases,  asstimes  an  icteroid  hue, 
which  is  especially  marked  about  the  face,  neck  and  shoulders. 
The  tongue  is  dry  and  covered  with  a  dirty  brownish  fur;  the 
gums  are  of  a  purplish  color.    The  nervous  restlessness  and  the 


202 


LECTURES  ON  FEVEBS. 


deliriam  return,  or  else  the  patient  lies  in  a  state  of  complete 
apathy  and  unconcern.  Frequently  muscular  spasms  and  sub- 
Bultus  tendinum  occur.  The  urine  is  scanty,  of  a  sulphur  or 
saffron  yellow  color,  and  contains — after  the  fifth  day — pranular 
tube  casts.  The  distress  and  burning  in  the  epigastrium  become 
more  and  more  severe.  As  the  vomiting  continues,  flakes  of 
black  hemorrhagic  matter  mixed  with  a  thin  mucoid  fluid,  and 
known  as  black  vomit  are  ejected.  The  vomiting  now  is  some- 
what peculiar  in  that  it  is  projectile  in  character.  It  may  occur 
on  the  second  or  third  day  of  the  fever,  but  more  commonly  it 
does  not  come  on  until  thirty-six  or  forty-eight  hours  before 
death.  The  ejection  of  the  black  vomit,  though  prostrating  to 
the  patient,  often  relieves  the  sensation  of  pressure  or  tightnesa 
over  the  epigastrium. 

Black  vomit. — When  allowed  to  stand,  black  vomit  separates 
into  a  thin  mucoid  fluid  and  a  solid  substance  resembling  coffee- 
grounds.  The  mucoid  fluid  is  made  up  mainly  of  water  mixed 
with  the  mucous  secretion  of  the  stomach.  The  solid  matters  of 
the  vomit  consist  of  colorless  blood  globules,  epithelium,  disin- 
tegrated matters  of  food,  and  free  haemoglobin  or  hsematin  in  the 
form  of  yellow  amorphous  patches.  Frequently  zoogloea  of  mi- 
crococcus are  observed  in  fresh  specimens.  And  very  often  speci- 
mens of  the  yeast  plant  or  cryptococcus  cerevisisB  are  found. 

If  the  disease  is  to  take  a  favorable  turn,  usually  after  a  con- 
tinuance of  twelve  hours,  amid  profuse  sweats  all  the  symptoms 
abate,  and  the  fever  gradually  subsides.  Ihe  pulse  falls  again, 
sometimes  as  low  as  forty  per  minute;  and  the  temperature 
slowly  returns  to  the  normal.  The  skin  becomes  moist,  and  the 
discoloration  fades.  The  gastric  sympt<jmB  become  greatly  di- 
minished; and  the  delirium  disappears.  Excessive  nervous 
prostration  now  remains  as  the  most  prominent  symptom.  As 
a  rule  convalescence  is  tardy,  being  frequently  protracted  by 
such  complications  as  diarrhea,  visceral  congestions,  abscesses, 
periostitis  of  the  tibia,  suppurative  parotitis,  etc. 

In  cases  which  are  to  terminate  fatally,  there  is  no  ameliora- 
tion, the  symptoms  becoming  more  and  more  grave  as  the  disease 
progresses.  The  temperature  steadily  rises,  while  the  pulse  fre- 
quently sinks.  The  tongue  is  hard,  dry  and  covered  with  a  brown 
or  blackish  fur.  The  black  vomit  increases;  and  frequent  hem- 
orrhages take  place  from  the  nose,  mouth,  kidneys  and  bowels. 


ANALYSIS  OF  CHART. 


203 


|ate  of  complete 
ims  and  sub- 
|of  a  sulphur  or 
day — pTinular 
[astrium  become 
inuos,  flakes  of 
ucoid  fluid,  and 
Ing  now  is  some- 
It  may  occur 
lore  commonly  it 
ht  hours  before 
;h  prostrating  to 
mre  or  tightness 

Tomit  separates 
Bsembling  coffee- 
r  of  water  mixed 
solid  matters  of 
pithelium,  disiu- 
)r  hsematin  in  the 
y  zooglcea  of  mi- 
very  often  speci- 
lisB  are  found, 
ually  after  a  con- 
all  the  symptoms 
pulse  falls  again, 
the  temperature 
es  moist,  and  the 
icome  greatly  di- 
ccessive  nervous 
it  symptom.    As 
ly  protracted  by 
stions,  abscesses, 
c. 

e  is  no  ameliora- 
ive  as  the  disease 
ile  the  pulse  fre- 
red  with  a  brown 
id  frequent  hem- 
eys  and  bowels. 


The  urine  becomes  very  scanty,  albuminous,  and  at  times  sup- 
pressed.  The  countenance  is  sunken,  and  the  face  is  of  a  dusky 
color.  The  delirium  may  be  either  low  muttering  or  active  until 
near  the  close  of  life.  In  severe  cases  hiccough,  clammy  sweats, 
convulsions,  and  involuntary  evacuations  precede  dissolution. 
Death  most  frequently  takes  place  on  the  fourth,  fifth  or  sixth 
day.  Some  epidemics  are  much  more  fatal  than  others.  The 
ratio  of  mortality  is  much  less  during  the  latter  part  than  dur- 
ing the  early  part  of  an  epidemic. 

Duration. — The  average  duration  of  yellow  fever  is  less  than 
one  week. 

ANALYSIS   OF   CHART. 

The  Cutaneous  Surface. — The  yellow  color  of  the  skin  from 
which  the  disease  receives  its  name — yellow  fever — is  reported 
as  being  present  in  not  more  than  one  case  in  six.  It  seldom 
appears  before  the  third  day.  It  is  first  noticed  about  the  eyes, 
whence  it  gradually  extends  downwards  over  the  whole  body. 
The  icteroid  hue  is  caused  by  the  staining  of  the  tissues  with 
pigment  matter  formed  from  the  loematin  during  the  degenera- 
tive changes  produced  by  the  action  of  the  yellow  fever  poison 
upon  the  red  globules  of  the  blood.  This  discoloration,  there- 
fore, is  a  real  hsematogenous  jaundice,  and  is  not  due,  as  some 
suppose,  to  a  retention  and  absorption  of  the  b^le. 

The  perapiration  becomes  especially  marked  after  the  first 
twenty-four  hours.  In  some  cases  the  sweat  is  so  profuse,  as  ta 
wet,  not  only  the  clothing,  but  also  the  bedding  upon  which  the 
patient  rests.  Along  with  the  sweat,  a  peculiar,  somewhat  cadav- 
erous odor  is  perceived  to  emanate  from  the  skin  and  in  the 
breath.  Frequently  a  burning,  stinging  sensation  is  imparted 
to  the  tips  of  the  fingers,  when  the  moist  and  feverish  skin  is 
touched.  In  severe  cases  the  face  is  of  a  dusky  hue,  though  the 
skin  generally  is  of  an  orange-yellow  color. 

The  Digestive  Tract.— The  tongue  is  early  covered  by  a 
white  cream-like  film,  except  at  the  tip  and  edges,  which  are  of 
a  bright  scarlet  tint.  Later  it  assumes  a  yellow  or  brownish 
tint,  and  the  edges  if  clean  are  of  a  purplish  color.  In  fatal 
cases  towards  the  close  of  life  it  becomes  hard,  dry,  and  covered 
with  a  brown  or  blackish  fur.  There  is  loss  of  appetite  with 
nausea  and  a  constant,  often  unsuccessful,  attempt  to  vomit  f romti 


304 


LECTUREH   ON  FEVERS. 

CHART  IX. -Yellow  Fcvcv. 


Xon-c'oiitiiM'iouN.                     Kiuleiiiic  or  Epiik'iiili.'.                     l'i>rtulil<>. 

Iiiciilmtion. 

Twelve  httnrs  to  tlve  days. 

IVii'UkIs: 

The  paroxysm. 

The  porioil  o(  Beituols. 

.stHKi'H: 

Statro  of  Initial  fever 

Stawe  <■('  calm. 

Stage  of 
reactionary  lever. 

Diii-Htlon: 

One  to  three  or  tour 
days. 

Twelve  hours  to  two 
days. 

Twelve  to  forty-eight 
hours. 

Teraperatui-e: 

104"  on  soeond  day. 

iW  Fahr.  or  normal. 

104"  Fahr. 

I'lilso: 

IK)  to  120,  ((faseoiia.) 

Approaches  the  noi^ 
mal. 

W  to  120. 
Thread-like. 

Skin: 

Yellow  on  third  day. 
Cadaveric  odor. 

Discoloration  sul>- 
sldcs. 

Orantie-yellDW  culor. 
Profuse  sweats    pre- 
cede eonvuiescence. 

Kyes: 

Muddy  at  first,  altei^ 

wards  suffused. 
Kosemblo  ballsof  tire. 

Subsidence  of 
symptoms. 

Ited  and  watery. 

Extremittea: 

Halnlnthe  buck  ami 
calves. 

Mu»c\ilar  prostration. 
Pain  In  back  and  legs 

Head: 

Hupra-orbitHl 
headache. 

Slight  cephalalgia. 

Apathy,  delirUim  or 
stupor. 

Tongii).': 

White  coat.    Ited 
edifss. 

White  coating. 

Dry,  brown,  cracked. 

Stomach : 

Nausea.     Projectile 

vomiting.     Vellow  or 

tri-ecnlsh . 

Epigastric  tender- 
ness. 

Projectile  vomiting. 

Blatk  vnmit. 

Hiccough. 

IJowels : 

Constlpatetl. 

Constipated, 

At  times,  hemorrhage 

!            Urino: 

Saffron  colored,   sup- 
pressed. 

Inci-eased  How. 

iniiria. 

ni<«Ml: 

Sorrat^u  globules.       Diminution  of  fibrin.            Uriemla. 

Kidneys: 

Parenchymatous  nephritis. 

Liver: 

Slightly  enlai-ged.                   Patty  dcuenrrattnn. 

Nervous  system: 

Intlammation  ot  lumbar  arachnoid,  and  ot  neurolemma  of  ganglia 
of  hepatic  and  ca-liae  plexuses. 

DurHlioii:         lAvcrajroof  disease,  6  days.          AverauriM)!' cpidcmU',  HO  toTOdays 

ProKnosts:       |    Mortality  varies  Irom  Tito "j  percent.     Most  fatal  In  ehildren. 

ANALYSIS   OF  CHART. 


200- 


the  onset  of  the  cliBeaBe.  And  generally  there  is  a  sensation  of 
dull  aching  pain  or  pressure  in  the  epigastrium.  Thirst  for  cold 
drinks  is  a  prominent  syniptoin.  .  ,    ,  .„      '  ■,        ,-    ,^„ 

VomUina  comes  on  soon  after  the  initial  chill,  and  continues 
throughout  the  course  of  the  fever.     At  first  the  vomited  matters 
consist  of  a  thin  mucoid  fluid,  of  a  white  and  frothy  appearance, 
frequently  mixed  with  bile.     Later-usually  in  the  third  stage- 
the  mucoid  fluid  becomes  mixed  with  flakes  of  black  hemorrha- 
cic  matter,  or  even  with  pure  blood.     As  the  vomiting  continues, 
the  flakes  of  black  hemorrhagic  matter  gradually  increase  iii 
amount,  until  finally  a  quantity  of  them  mixed  with  thin  mucoid 
fluid-and  styled  the  black  vcnnii-iB  thrown  up  forcibly,  and  at 
once     This  peculiar  vomit,  which  is  brownish-black  in  appear- 
ance" is  an  almost  pathognomonic  sign  of  the  disease,  and  may 
vary'in  quantity  from  a  mere  stain,  to  many  pints  in  twenty-four 
hours     It  may  occur  as  early  as  the  second  or  third  day,  but 
usually  it  does  not  set  in  until  thirty-six  or  forty-eight  hours  be- 
fore death.    Statistics  show  that  it  is  present  in  not  more  than 
thirty-three  per  cent' of  all  dying  cases.   WheA  present  rt  should 
always  be  regarded  as  a  grave  symptom.     Children  are  more 
apt  to  recover  after  it  has  occurred,  than  are  grown  people.     In 
some  oases,  black  matters  resembling  black  vomit  are  passed 
from  the  bowels,  which,  otherwise,  are  constipated.     In  many 
instances  hiccough  appears  as  the  patient  approaches  collapse 
Critical  alvme  evacuations  frequently  precede  an  abatement  of 
febrile  symptoms.  .  ,     •  4. 

The  Urine.— Early  in  the  fever  the  urine  has  a  reddish  tint 
and  displays  an  acid  reaction.     After  the  second  day  it  almost  in- 
variably  contains  albumen.     Granular  tube  casts  may  be  dis- 
covered  on  the  fifth  day.     Albumen  is  found  in  all  fatal  cases. 
In  severe  cases  the  urine  becomes  very  scanty,  contains  a  mini- 
mum of  urea,  and  may  be  suppressed  from  twelve  to  forty-eight, 
hours     Suppression  of  urine  usually  occurs  during  the  latter 
part  of  the  third  stage,  and  is  one  of  the  most  dangerous  symp- 
toms     "When  complete  it  is  more  unfavorable  than  the  black 
vomit,  as  death  may  speedily  ensue  from  ur*mia.     Biliaxy  pig- 
ment appearing  towards  the  close  of  the  disease  is  generally  con- 
sidered a  favorable  symptom. 

The  Eyes.— At  the  onset  the  eyes  present  a  muddy  appear- 
ance owing  to  slight  oedematous  swelling  of  the  conjunctiva. 


906 


LEOTCBES   ON  FEVERH. 


I 


Later,  from  increased  conjunctival  congestion,  they  become  moist, 
and  resemble  balls  of  fire. 

The  Temperature. — The  characteristic  symptom  as  regards 
temperature  in  yellow  fever  is,  that  the  highest  jMjint  is  reached 
at  the  outset  of  the  disease.  In  mild  cases  the  maximum  is 
reached  within  a  few  hours  after  the  initial  chill,  while  in  pro- 
tracted cases  it  is  seldom  delayed  beyond  the  second  or  third 
day.  Fig.  13  (j).  207.)  represents  the  temperature  curve  in  typ- 
ical cases  of  two,  four,  and  eight  days  duration. 

During  the  paroxysm  the  average  height  reached  in  the  axilla 
is  104"  Fahr.  In  exceptional  cases  it  may  mount  to  106°  Fabr. 
or  higher.  In  the  stage  of  calm  it  falls  to  100  Fahr.,  but  rises 
again  to  104°  Fahr.  or  even  higher  as  the  patient  enters  the  third 
stage.  After  remaining  stationary  for  from  twelve  to  forty-eight 
hours,  it  falls  to  the  normal  standard,  where  it  remains  until  con- 
valescence is  fully  established.  A  considerable  rise  in  tempera- 
ture frequently  occurs,  shortly  before  death,  in  fatal  cases. 

The  following  iable  arranged  by  Sternberg,  shows  the  prog- 
nostic value  of  temperature  observations  in  yellow  fever. 


fuses  huviug 
temperature  of 

\o.  of  Cases. 

No.  of  Dcatlw. 

I'erccntage  of  Deaths 
to  Ciises. 

107°  uud  above 
From  106°  to  107" 
105"  —  106" 
104"  —  105" 
103"  —  104" 
102"  —  103" 
101"  —  102" 

13 

9 

•M 

80 
87 
29 
15 

13 
9 
22 
24 
6 
0 
0 

100 

100 

61 

30 

7 

Total 

269 

i              74 

27-5 

The  Pulse. — The  pulse  is  most  rapid  at  the  outset  of  the 
fever.  Its  maximum  average — 120  beats — is  reached  on  the 
first  day.  Immediately  afterwards  it  begins  to  fall  at  about  the 
rate  of  ten  beats  every  twenty-four  hours.  This  steady  decline, 
which  begins  as  early  as  the  second  day,  when  taken  in  connec- 
tion with  the  rise  in  temperature,  is,  I  would  have  you  remem- 
ber, one  of  the  most  reliable  guides  in  the  differential  diagnosis 
of  this  disease. 

The  Neryous  System. — Slight  headache  occurs  among  the 
early  prodromes.  Then  comes  the  chill  or  rigor,  followed  by 
general  symptoms  of  hypersemia  of  the  cerebro-spinal  axis,  and 


.'assR's 


TEMPERATURE   RANGE. 


20V 


ley  become  moist, 

kptom  nn  regards 
J  ixjint  is  reached 
ItJie  maximum  is 
|ill,  wliile  in  pro- 
second  or  third 
re  curve  in  typ. 

ihed  in  the  axilla 
mt  to  106°  Fahr. 
Fahr.,  but  rises 
tenters  the  third 
ilvetoforty-eight 
emains  until  con- 
rise  in  tempera- 
fatal  cases, 
shows  the  prog- 
low  fever. 


ercentage  of  Deaths 
to  CiiHeH. 


27- 


le  outset  of  the 
reached  on  the 
fall  at  about  the 
3  steady  decline, 
aken  in  connec- 
ive  you  remem- 
ential  diagnosis 


iurs  among  the 
or,  followed  by 
spinal  axis,  and 


Fi 

a.   1 

3. 

Day 

1 

2 

3 

4 

5 

0 

' 

8 

0 

10 

11 

13 

13 

14 

15 

10.-) 

104 

103 

2 

Day 

i 

103 

\. 

101 

V 

A, 

100 

> 

I 

00 

V 

W 

y^ 

> . 

/\ 

/^ 

/ 

J 

V 

08 

103 

•^ 

■A 

104 

\ 

103 

\ 

\ 

4 

Doy 

1 

102 

\ 

• 

101 

\ 

/ 

100 

\ 

V\ 

/ 

V 

\, 

J 

00 

J 

\ 

/ 

V 

\/ 

\a 

08 

1 

u 

^ 

^v^ 

V^ 

105" 

104 

103 

A 

/ 

\, 

8 

Day 

i 

103 

s/ 

-\ 

101 

\ 

/ 

\ 

100 

v 

\ 

./ 

^ 

i 

\ 

00 

A 

^ 

y 

V 

\/ 

V 

08 

^^_ 

I- 

y 

V 

v/ 

r 

Temperature    Uuiigu  in  typiejil  cases  ol"  Yellow  Fever,  of  two,  four,  aud 
eight  days  duration  (aiter  Sternberg.) 


-MaiMMiWMM 


mmmmm 


mmmmmm- 


208 


LECTUnES  ON  FEVERS. 


of  the  syrapatlietic  ganglia  of  the  abdomen  and  thorax.  Mild  de- 
lirium frequently  occurs  aH  early  as  the  Hec(md  day.  In  many  caseri 
the  delirium  l)ecome9  wild  in  character,  and  is  marked  by  a  con- 
stant desire  on  the  part  of  the  patient  to  escape.  In  cases  which 
terminate  fatally  the  delirium  usually  remains  active  till  death 
approaches.  In  the  "  apoplectic  grade  "  the  patients  are  struck 
down  suddenly,  become  perfectly  comatose,  hemorrhages  take 
place,  and  death  speedily  ensues.  The  fatality  in  most  instances 
is  almost  always  dependent  uiKin  hypenemia  of  the  brain.  In 
cases  that  recover,  excessive  nervous  prostration,  and  the  general 
feebleness  of  the  organism  render  convalescence  tardy  and  oft- 
times  discouraging. 

Morbid  Anatomy. — The  anatomical  changes  which  occur  in 
yellow  fever  resemble  in  many  respects  those  of  the  miasmatic 
and  contagious  fevers. 

The  Liver.—The  liver  is  the  seat  of  the  most  constant  and 
characteristic  lesion  of  the  disease.  The  typical  pathological 
change  is  one  of  fatty  infiltration,  and  may  involve  the  whole 
gland,  or  be  confined  to  one  lobe  or  to  a  small  portion  of  a  lobe. 
On  section  the  organ  presents  a  peculiar  pale  yellow,  greenish  or 
blackish-brown  appearance.  Viewed  under  the  microscope  the 
hepatic  cells  are  observed  to  be  more  or  less  filled  with  oil 
globules.  Sometimes  the  pathological  changes  advance  to  a  true 
fatty  degeneration  of  the  protoplasm  of  the  hepatic  cells.  In 
such  cases  tlje  entire  liver  cells  will  appear  filled  with  large  fat 
globules;  presenting  the  condition  known  as  acute  fatty  degen- 
eration. Very  frequently,  especially  in  drunkards,  cirrhosis  is 
associated  Math  fatty  degeneration. 

The  Kidneys. — The  kidneys  are  always  more  or  less  congested 
and  enlarged,  and  their  pelves  are  frequently  the  seat  of  catarrhal 
inflammation.  In  the  majority  of  fatal  cases,  the  leading  patho- 
logical change  consists  in  a  degeneration  of  the  epithelium  lin- 
ing the  uriniferous  tubules.  As  a  result  of  the  degeneration, 
numerous  sn-called  albuminous  cylinders  are  formed  in  the  in- 
terior of  the  tubules.  The  largest  of  these  cylinders  are  formed 
in  the  convoluted  portions — the  tubuli  contorti — and  in  the  in- 
termediate canals.  During  the  metamorphosis  larger  fat  glob- 
ules are  rarely  observed. 

The  suppression  of  urine  which  appears  in  some  cases  is  prob- 


.ijm.iiLiiiiuj!w^BiwwBwaii 


MORBID   ANATOMY. 


309 


hornx.    Mildde. 
'.  In  ninny  cnBes 
nrked  by  a  con- 
In  cases  which 
nctive  till  death 
iients  are  struck 
•morrhages  take 
[n  most  instances 
the  brain.      In 
J,  and  the  general 
36  tardy  and  oft- 

which  occur  in 
f  the  miasmatic 

)st  constant  and 
cal  pathological 
volve  the  whole 
artion  of  a  lobe, 
low,  greenish  or 
>  microscope  the 
i  filled  with  oil 
idvance  to  a  true 
»patio  cells.    In 
d  with  large  fat 
ate  fatty  degeu- 
rds,  cirrhosis  is 

r  less  congested 
eat  of  catarrhal 
leading  patho- 
epithelium  lin- 
•  degeneration, 
■med  in  the  in- 
lers  are  formed 
-and  in  the  in- 
»rger  fat  glob- 


ably  duo  to  general  atrophy  and  degeneration  of  the  renal  epithe- 
lium. 

The  Heart. — In  uncomplicated  cases  the  heart  is  generally 
found  normal  in  size  and  form,  empty,  and  firmly  contracted. 
At  times  it  is  pale,  soft  and  flabby,  and  presents  clianges  similar 
to  those  found  in  typhoid  fever.  The  pericardium  often  con- 
tains from  one  to  two  ounces  of  yellow  or  reddish  serum. 
Partially  organized  yellowish  coagula,  resulting  from  the 
Hlowing  of  the  circulation  from  the  feebleness  of  heart  power, 
are  occasionally  found  in  the  cavities  of  the  heart. 

The  Blood. — The  fibrin  of  the  blood  is  diminished  in  quantity. 
The  colored  corpuscles  undergo  changes  which  iulicate  loss  of 
vitality.  The  white  corpuscles  are  reduced  in  number,  and  con- 
tain an  unusual  quantity  of  fat  granules. 

When  removed  from  the  body,  the  blood  of  yellow  fever  rapidly 
undergoes  ammoniacal  changes. 

The  Brain, — The  nervous  system  is  always  seriously  impli- 
cated. The  pia  mater  is  almost  invariably  found  in  a  state  of 
hyperemia.  The  arachnoid  is  frequently  found  not  only  opaque 
but  thickened.  The  brain  is  congested  throughout  its  whole 
substance,  but  more  especially  in  the  parietal  lobes.  The  general 
cerebral  hyperaemia  depends  upon  a  depression  of  the  vaso-motor 
nerves,  followed  by  a  relaxation  of  the  arterial  walls. 

Cadaveric  rigidity  appears  early  and  is  strongly  marked. 

The  Stomach. — In  almost  all  cases  the  mucous  membrane  of  the 
stomach  is  found  more  or  less  congested.  The  congestion  is  con- 
fined to  smaller  or  larger  spots,  and  appears  mostly  along  the 
greater  curvature.  In  fatal  cases,  small  red  spots  or  patches,  re- 
sembling small  ecchymoses  or  extravasations  of  blood  are  found. 

The  Skin. — The  intensity  of  the  color  of  the  skin  varies  usu- 
ally in  proportion  to  the  severity  of  the  case.  It  is  of  an  orange- 
yellow  color,  and  is  deepest  about  the  head  and  trunk,  fading 
towai^ls  the  feei  Frequently,  approaching  the  end  of  an  epi- 
demic, the  discoloration  extends  only  to  or  slightly  below  the 
knees. 

In  most  instances  the  almost  characteristic  yellow  tint  is  ob- 
served in  all  the  tissues  of  the  body. 


1 
I 


cases  is  prob- 


r 


LECTURE  XIV.  ' 

Yellow  Fover^( Continued.) 

In  the  lecture  immediately  preceding  I  gnve  yoa  the  main 
points  in  the  clinical  history  and  morbid  anatomy  of  yellow 
fever ;  I  will  now  state,  as  fully  as  the  limits  of  the  hour  will 
permit,  what  is  at  present  known  concerning  its  differential 
diagnosis  and  treatment. 

Differential  DIagnoHls.-It  is  almost  impossible  to  make  on 
infallible  diagnosis  of  yellow  fever  at  the  outset  of  the  diseose, 
as  a  number  of  other  infectious  maladies  approach  in  a  similar 
manner,  and  are  attended  by  the  same  phenomena.  On  and  after 
the  second  day,  however,  the  recognition  is  generally  eosy.  The 
falling  of  iho.  pulse  on  the  second  day,  with  a  simultaneous  rise 
of  the  temperature  of  the  body;  the  pain  in  the  head,  back,  ond 
calves  of  the  legs;  the  suffused  and  watery  eye;  the  presence  of 
albumen  in  the  urine  on  the  third  day;  the  epigastric  tender, 
ness;  the  projectile  vomiting;  the  orange-yellow  color  of  the  skin- 
the  black  vomit;  and  the  short  duration  of  the  febrile  phenomena, 
constitute  a  group  of  symptoms  which  are  unmistakable.  While 
fatty  infiltration  of  the  liver,  along  with  the  peculiar  spotted  con- 
gestion  of  the  stomach,  and  the  black  vomit,  are  pathognomonic 
autopsic  phenomena  of  the  disease. 

Yellow  fever  may  be  confounded  with  remittent  fever,  relaps- 
ing fever,  and  acute  yellow  atrophy  of  the  liver. 

Eemittent  fever  is  a  disease  of  several  paroxysms,  prevails  in 
inland  towns,  and  is  not  portable.  Yellow  fever  is  a  disease  of 
one  paroxysm,  prevailo  in  seaports,  and  is  portable.  The  vomit- 
ing 13  projectile  in  character  in  yellow  fever;  it  is  non-projectile 

1.210.) 


••i~JiiinjmirniirTinitwwi»MiiKMiiiili^ 


riioo<)io«iH. 


an 


in  rnmlttent  fnvor.     In 
«l'iy  fiillH   whiln  tlio  ti 


!D.) 

ftve  you  tlio  main 
imtoniy  of  yellow 
B  of  the  hour  will 
ng  its  differential 

issible  to  make  an 
set  of  the  disease, 
roach  in  a  similar 
5na.    On  und  after 
lerally  easy.     The 
simultaneous  rise 
le  head,  back,  and 
3;  the  presence  of 
epigastric  tender- 
'^  color  of  the  skin; 
Jbrile  phenomena, 
istakable.   While 
uliar  spotted  con- 
•e  pathognomonic 

ent  fever,  relaps- 

ysms,  prevails  in 
er  is  a  disease  of 
We.  The  vomit- 
is  non-projectile 


yf>11<>w  fever  tlio  jiiilso  nftor  tho  Ht'cond 
MH>niturH  rirtPs;  in  r#'t)iitt(*nt  fcvnr  it 
rimiH  and  falls  witli  tho  fo\.  '  hoat.  Th^  yellow  dmcoloration  of 
tho  nkin  apponrH  oarlicr  and  i«  /<ii>rn  intense  in  y»>llow  fever  than 
in  remittent  fever.  Tho  urino  Ih  ^.Merally  albuminutis  in  yellow 
fever,  rarely  ho  in  remittent  fever.  'J'he  npleen  is  l)nt  Hliglilly 
or  not  at  nil  nflfected  in  the  former,  while  it  \a  invariably  en- 
larged in  the  latter.  Black  pigment  granuleH  (i'ifjj.  0),  which 
are  found  in  the  blood  in  remittent  fever,  are  not  seen  in  yellow 
fever.  One  attack  of  yellow  fever  aff«>rds  almoBt  certain  immu- 
nity, while  one  of  remittent  rather  i)rediHpo8es  to  others.  Au- 
toi«ies  show  a  yellow,  fatty  liver  in  yellow  fever,  and  a  non- 
fatty  bronzed  liver  in  remittent  fever. 

Rflapsiug  or  spirillum  fever  is  contagious.  Yellow  fever  is 
non-contagious.  The  discoloration  of  the  skin  in  relapsing  fever 
seldom  appears  l)efore  the  relapse,  while  in  yellow  fever  it  fre- 
quently appears  about  the  third  day.  Spirilla  are  found  in  the 
blood  of  the  former,  but  not  in  that  of  the  latter.  The  spleen 
which  usually  remains  unaltered  in  yellow  fever  is  as  a  rule  en- 
larged in  relapsing  fever. 

Acnlc  yellow  atrophy  of  tlie  liver  may  be  differentiated  from 
yellow  fever  by  its  history  and  by  the  steady  diminution  in  size 
of  the  organ. 

Prognosis. — The  prognosis  is  much  more  favorable  under 
homoeopathic  than  under  old  school  treatment;  as  under  the  for- 
mer the  mortality  is  from  five  to  twelve  per  cent;  while  under 
the  latter  it  ranges  from  fifteen  to  seventy-five  per  cent.  It  varies 
greatly  in  different  epidemics,  and  at  different  periods  of  the  same 
epidemic.  It  is  favorable  when  the  febrile  paroxysm  is  long  and 
moderate,  and  when  the  albuminous  urine  does  not  contain  casts. 
It  should  be  guarded  in  new  comers,  and  when  the  temperature 
runs  high,  the  stomach  is  irritable,  or  the  urine  becomes  scanty 
and  contains  albumen  and  casts.  It  is  always  grave  when  black 
vomit  and  urinary  suppression  supervene.  According  to  statis- 
tics recovery  is  more  frequent  after  the  occurrence  of  black 
vomit,  than  after  suppression  of  urine.  Coma  and  convulsions 
are  usually  fatal  symptoms  dependent  on  uraemia. 

Treatment. — Proptiylaxis. — In  the  prevention  of  yellow  fever 
your  attention  must  be  directed  in  the  first  place  to  the  inter- 
ception of  its  new  importation,  and  in  the  second  place  to  the 


i: 


1 


*  ■ 

I 
i 


219 


LECTURES  ON  FEVEUS. 


thwarting  of  its  spreading  aftor  it  has  once  mnclo  its  appearance^ 
A  properly  regulated  and  executed  system  of  quaraniine  will — 
as  far  as  is  possible — prevent  the  early  introduction  of  the  spe- 
cific poison.  And  further,  local  hygiene  and  the  best  panitary 
measures,  are  of  almost  equal  importance  with  quarantine  in 
checking  the  spread  of  imported  yellow  fever,  and  are  of  abso- 
lute necessity  in  the  pre.'ontion  of  that  of  domestic  origin.  For 
importation  of  the  morbific  agent  is  not  always  necessary,  as 
germs  may  be  perpetuated,  from  epidemics  of  previous  years, 
through  the  winter  months,  to  break  forth  as  soon  as  ihe  intense^ 
heats  of  summer  come  to  recuperate  them,  and  enable  them  to 
develop  and  multiply. 

The  question  of  yellow  fever  quarantine  is  a  very  vexed  one. 
And  as  many  of  the  best  physicians  entertain  entirely  different 
views,  it  will  be  of  little  use  to  discuss  the  matter  here.  Suffice^ 
it  to  say  that  most  exhaustive  papers  on  the  subject  are  contained 
in  the  Keport  of  the  Bureau  of  Sanitary  Science  to  the  Americaa 
Institute  of  Homoeopathy  at  its  thirty-third  session,  in  1880. 

All  vessels  arriving  from  yellow  fever  ports,  during  summer 
months,  near  ports  liable  to  it,  should  be  inspected,  and  undergo 
thorough  cle  vnsing  and  disinfection.  If  found  to  be  infected, 
such  vessel  or  vessels  should  be  quarantined  until  a  thorough 
disinfection  of  the  clothes  and  effects  of  sailors  and  passengers^ 
together  with  the  cabins  and  general  hold  of  the  ship  or  ships 
has  been  obtained.  (Personal  detention,  other  than  of  those  ill^ 
is  seldom  necessary.)  The  clothes  of  passengers  may  be  readily 
disinfected  by  dry  heat,  as  most  germs  of  disease  become  in- 
noxious with  a  temperature  of  212°  Fahr.  The  deck  and  wood- 
work should  be  washed  in  carbolized  water,  and  the  ship  thor- 
oughly disinfected  with  either  chlorine  or  sulphur  dioxide.  The 
space  to  be  disinfected  must  be  kept  saturated  with  the  gas  for 
not  less  than  one  hour. 

As  yellow  fever  usually  proceeds  along  the  highways  of  travel, 
cities  and  towns  located  within  the  fever  zone,  should  quarantine 
against  infected  districts.  Non-infected  wards  of  a  city  or  town 
should  also  institute  quarantine  regulations  against  infected  ones, 
as  the  immediate  limits  of  the  disease  may  mostly  be  measured 
by  fractions  of  a  square  mile.  Camps  of  refuge  should,  when 
possible,  bfc  provided  at  convenient  distances — say  five  or  ten 
miles — from  the  city  or  town  infected.    Every  sporadic  case  of 


PBINCIPAL  REMEDIES. 


213 


iclo  its  appearance. 
quaraniine  will — 
notion  of  the  spe- 
l  the  best  panitary 
vith  quarantine  in 
ir,  and  are  of  abso- 
lestic  origin.  For 
yays  necessary,  as 
of  previous  years, 
3oon  as  ihe  intense- 
ind  enable  them  ta 

I  a  very  vexed  one. 
1  entirely  different 
itter  here.  Suffice 
bject  are  contained 
ce  to  the  American 
session,  in  1880. 
rts,  during  summer 
ected,  and  undergo 
ind  to  be  infected, 
d  until  a  thorough 
)r8  and  passengers,. 
if  the  ship  or  ships 
Br  than  of  those  ill,^ 
;er8  may  be  readily 
lisease  become  in- 
'he  deck  and  wood- 
and  the  ship  thor- 
phur  dioxide.  The 
id  with  the  gas  for 

highways  of  travel, 
,  should  quarantine 
is  of  a  city  or  town 
;aiust  infected  ones, 
aostly  be  measured 
(fuge  should,  when 
es — say  five  or  ten 
y  sporadic  case  o£ 


yellow  fever  occurring  in  cities  should  be  sent  at  once  to  the 
quarantine  hospital  for  treatment. 

In  the  midst  of  an  epidemic,  depopulation  of  rooms  and  avoid- 
ance of  confined  areas  of  stagnant  air,  afford  the  safest  personal 
prophylaxis.     People  should  live  in  the  open  air.     The  city 
should  be  kept  in  the  best  sanitary  condition,  and  no  anima 
matter  should  be  allowed  to  decay  within  its  limits.    Personal 
contact  with  anyone  after  the  fever  rises,  and  until  it  ceases, 
shoukl  be  avoided.  Cimicifuga  and  crotalus  are  recommended  as 
preventives.     In  the  sick  room  free  ventilation,  cleanliness,  and 
other  sanitary  measures  are  of  the  utmost  importance.    All  ex- 
creta and  vomited  matters  should  be  placed  in  earthen  vessels 
and  thoroughly  disinf ected-without  delay— before  being  thrown 
out     Piatt's  chlorides  should  be  sprinkled  around  the  room  and 
on  the  bed-clothing.     All  the  bedding,  together  with  the  bed  and 
Taody  linen  should  be  bumed  as  soon  as  the  patient  is  m  conva- 
lescence.   Woolen  articles  may  be  disinfected  by  heat  at  a  tem- 
perature slightly  above  212°  Fahr.     All  other  articles  that  will 
stand  boiling  and  washing  with  carbolized  water  and  soap,  should 
undergo  the  process.     After  the  patient  has  either  recovered  or 
died  the  room  should  be  well  and  completely  ventilated,  disin- 
fected with  sulphur  dioxide,  oi  frozen  out-and  this  must  be  for 
at  least  seven  consecutive  days.     The  floors  and  wood-work  of 
the  apartment  should  be  washed,  and  the  walls  whitewashed  or 
if  already  papered,  thoroughly  disinfected.     That  method  of 
aerial  disinfection  which  as  formerly  practiced,  simply  consists 
in  making  the  air  of  a  room  smell  strongly  of  carbolic  acid,  by 
scattering  carbolic  powder  on  the  floor,  or  of  chlorine  by  placing 
a  saucer  of  chloride  of  lime  in  one  corner  of  the  apartment,  is  a 
delusion,  and  as  far  as  the  destruction  of  epecific  germs  is  con- 
cenied  is  perfectly  useless.  ^  •,  j-  ^  •  4. 

No  one  should,  after  leaving,  return  to  an  infected  district, 
until  at  least  four  weeks  after  the  last  case,  or  after  a  seven  days* 
ireeze. 

Principal  Remedies.— The  most  important  remedies  during 
the  cold  period  of  the  first  stage  are:  Tinct  of  camphor,  and 
verairum  alb.  As  soon  as  a  reaction  appears,  and,  in  general 
terms,  during  the  first  twenty-four  hours  thereafter,  aconite  is 
indicated  During  the  second  twenty-four,  belladonna  is  usually 
the  remedy,  and  during  the  third,  brymta.     Veratrum  viride  is 


LECTURES  ON  FEVERS. 

occasionally  of  service.  Oclsendum  and  eupatoriun  perf.  vie 
with  the  foregoing  remedies  in  the  stage  of  initial  fever,  espe- 
cially if  malarial  complications  exist.  Quin'me  may  also  prove 
of  service  in  such  cases,  particularly  Avhen  prostration  begins  to 
appear,  and  when  in  consequence  of  malarial  influences  fatal 
congestions  threaten.  It  should  be  administered  hypodermatic- 
ally  and  in  appreciable  doses,  as  suggested  in  a  former  lecture 
on  Pernicious  Fever  (p.  99). 

Arsenicnm  alb.  will  be  your  main  reliance  in  the  stage  of 
calm,  although  possibly  if  malarial  influences  predominate  it 
may  give  way  to  either  cinchona  or  natrum  mnriaiieum. 

During  the  stage  of  reactionary  fever,  arsenicum  is  the  rem- 
edy, par  excellence.  After  it  comes  lachcsis  or  possibly  crotalus. 
In  typhoid  states  either  rhus  tox.  or  arnica  may  be  indicated. 
And  in  collapse  you  will  need  either  arsenicum,  crotalus,  carbo 
vey.,  or  hydrocyanic  acid.  Calcarea  carb.,  or  cinchona  may 
prove  serviceable  during  convalescence. 

As  intercurrent  remedies,  you  will  think  of: — 

Bell,  caffeine,  hyosc.  or  potassium  bromide  (per  rectum),  for 
the  insomnia  and  nervous  agitation.  Ipecac  for  obstinate  vom- 
iting in  the  first  stage,  and  stdpho-carbolate  of  soda,  in  from  two 
to  five-gi'ain  doses  when  it  occurs  in  the  last  stage.  Verat.  alb. 
for  vomiting  with  abdominal  pain  and  great  prostration.  Tar- 
tar ei  ict.  when  there  is  prolonged  and  distressing  nauseft,  in  the 
third  stage.  Arycnttim  nit.,  arsenicnm,  or  cadmium  sulphate 
for  the  black  vomit.  Mercurius  or  colocynth,  when  either  diar- 
rhea or  dysentery  supervene.  Millefolium  or  gallic  acid  for 
liemorrhage  from  the  mouth  and  gums.  Argent,  nit.,  ars.  alb., 
crotahis,  sulphuric  acid  or  phos.  for  hemorrhage  from  the  intes- 
tinal canal.  Lycoxiodium,  terebinthina  or  erigeron  for  hemor- 
rhage from  the  kidneys  or  bladder.  Sabina  for  either  uterine 
hemorrhage  or  threatened  abortion.  Euouymin,  helonin,  mere, 
cor.,  or  cuprum,  for  albuminuria.  Opium  or  hyosc.  for  urinary 
retention.  Cantharis  or  apis  for  difficult  urination,  with  scanty 
discharge,  and  cucumis  citrtdlus — a  decoction  of  watermelon 
seeds — in  urinary  suppression  when  other  remedies  fail. 

Leading  Indications. — The  following  are  the  guiding  symp- 
toms for  the  diflferent  remedies: — 

Aconite. — Excessive  restlessness  and  anxiety.    G  reat  timidity ; 
fear  of  api)roaching  death.    Vertigo  on  rising.    Burning  head- 


mwiimiai 


mmm 


IMM 


LEADING   INDICATIONS. 


215 


uriun  perf.  vi» 
tial  fever,  espe- 
may  also  prove 
ration  begins  to 
iniiuences  fatal 
i  liypodermatic- 
b  former  lecture 

in  the  stage  of 
predominate  it 
aiiciim. 

'cum  is  the  rem- 
ossibly  crotalua, 
ay  be  indicated. 
crotalus,  carbo 
'  cinchona  may 


per  rectum),  for 
r  obstinate  vom- 
xki,  in  from  two 
ige.  Verat  alb. 
ostration.  Tar- 
ig  nausefl,  in  the 
dmiiim  sulphaie 
hen  either  diar- 
'  gallic  acid  for 
lit  nit,  ars.  alb., 
5  from  the  intes- 
'Ton  for  hemor- 
r  either  uterine 
I,  helonin,  mere, 
'/osc.  for  urinary 
tion,  with  scanty 
1  of  watermelon 
dies  fail, 
e  guiding  symj)- 

G  rest  timidity; 
Burning  head- 


ache. Pain  in  the  forehead  and  temples.  Face  dark  red;  on 
rising  turns  deadly  pale.  Eyes  injected  and  sensitive  to  light. 
Great  sensitiveness  t»>  every  noise.  Epistaxis.  Dryness  of  the 
mouth  and  lips.  Thirst  for  large  quantities  of  water.  Burning 
and  numbness  in  the  throat.  Nausea,  vomiting  and  painful  hic- 
cough. Heat  and  tenderness  of  the  epigastrium.  Pain  in  the 
back  and  extremities.  Painful,  anxious  urging  to  urinate.  Great 
weariness  and  loss  of  strength. 

Apis  iiiel.— Absent  mindedness  and  indifference.  Headache, 
pain  in  the  forehead  and  temples  relieved  by  pressure.  Red, 
hot,  swollen  facs.  Dryness  of  tlie  tongue,  scalding  in  the  mouth 
and  throat.  Dysphagia.  Suppression  of  urine.  Strangury,  or 
else  urine  scanty  and  high  colored.     Great  desire  to  sleep. 

Argentum  nit.— Headache,  with  boring  in  left  frontal  emi- 
nence, relieved  by  pressure.  Intolerance  of  light.  Conjunctiva 
pink  or  scarlet-red.  Yellow,  dirty-looking  face.  Tender,  easily 
bleeding  gums.  Throat  dark  red.  Black  vomit.  Tremulous 
weakness.  Convulsions  preceded  by  great  restlessness.  Sense 
of  expansion  of  the  body,  particularly  of  the  face  and  head. 

Arsenicum  alb.— Great  restlessness  and  anxiety,  especially  at 
night.  Dread  of  death.  Delirium  with  desire  to  escape.  In- 
tense, dull  or  throbbing  pain  in  the  head.  Excessive  photopho- 
bia. Yellowness  of  the  conjunctiva.  Dark  rings  around  the 
eyes.  Yellow  or  livid  face.  Dry,  brown  or  black  tongue.  Vio- 
lent  thirst;  drinks  little  but  often.  Vomiting,  especially  after 
drinking.  Great  anxiety  in  the  epigastrium.  Black  vomit.  Vio- 
lent burning  pains  in  the  abdomen  with  intolerable  anguish. 
Black,  putrid,  bloody  stools.  Suppression  or  retention  of  urine. 
Involuntary  urination.  Bloody  urine.  Oppression  of  the  chest 
with  short,  anxious  breathing.  Irregular,  small,  scarcely  per- 
ceptible pulse.  Bruised  pain  in  the  small  of  the  back.  Drawing 
pains  in  the  legs.  Sudden  sinking  of  strength.  Coldness  of 
the  body,  with  internal  burning  heat.     Cold,  clammy  sweat. 

Baptisia. — General  indisposition.  Confusion  of  mind.  Fron- 
tal headache  with  pressure.  Lameness  and  soreness  of  eyeballs 
on  moving.  Dark,  red,  besotted  expression.  Dryness  of  the 
mouth  and  tongue.  Foetid  breath ;  difficult  deglutition.  Dark 
red  scanty  urine.    Severe  aching  pain  in  the  back  and  hips. 


216 


LECTURES  ON  FEVERS. 


Tired,  bruised,  sick  feeling  all  over.     Delirious  stupor.     Symp- 
toms worse  from  evening  until  midnight. 

Belladonna. — Great  anxiety  and  restlessness,  with  desire  to 
escape.  Vertigo  on  turning  over  in  bed.  Nervous  excitement 
with  delirium.  Cephalalgia  with  throbbing  of  tlie  carotids. 
Pain  relieved  by  pressing  strongly  on  the  forehead.  Eed,  swol- 
len, staring  eyes;  intolerance  of  light;  dilated  or  oscillating  pu- 
pils. Eed  halo  around  the  light.  Bright  red,  swollen  face. 
Dryness  of  the  mouth,  tongue  and  throat.  Burning  and  throb- 
bing in  the  stomach,  with  excessive  thirst  for  cold  water.  Ee- 
tention  of  urine.  Menses  too  early  and  too  profuse.  Dry, 
burning  heat  with  changing  pulse.  Pain  iii  the  back,  loins  and 
extremities.  Intense  burning  heat  within  and  without.  In 
plethoric  individuals, 

Bryonia. — Irritable  mental  state.  Sensation  as  if  sinking 
deep  down  in  bed.  Headache  from  the  occiput  down  to  the  ueck 
and  shoulders,  us  if  head  would  split,  worse  from  motion.  Pain, 
especially  in  the  left  eyeball,  aggravated  by  motion.  Dark  red 
puffy  face.  Great  dryness  of  the  mouth  and  tongue.  Thick 
white  or  brownish  coating  on  the  tongue.  Bitter,  sour  taste. 
Excessive  thirst  for  large  quantities  of  water.  Fullness  and 
pressure  in  the  epigastric  region.  Vertigo  or  nausea  on  sitting 
up.  Dark,  almost  brown,  scanty  urine.  Full,  hard,  rapid  pulse. 
Pain  in  the  back,  limbs,  and  abdomen.  Worse  in  warm  weather 
after  cold  days. 

Cadmium  8ulpli. — Vertigo,  nausea,  pitch-like  taste  in  the 
mouth;  salty,  rancid  eructations.  Burning  and  cutting  in  the 
stomach;  vomiting  of  sour,  yellowish  or  blackish  fluid.  Pain  in 
the  abdomen.    Cold  sweat  on  the  face. 

Camplior. — Severe  and  long-lasting  chill.  Great  anxiety  and 
restlessness.  Pale,  anxious  expression.  Weak,  scarcely  percep- 
tible pulse.  Icy  coldness  of  the  whole  body.  Cold,  clammy 
sweat.    Internal  trembling;  great  prostration. 

Cantharis. — Insensibility.  Yellowness  of  the  conjunctiva. 
Suppression  or  retention  of  urine.  Bloody,  turbid,  scanty  urine. 
Pain  in  the  loins,  kidneys  and  abdomen.  Tearing  in  the  limbs; 
cold  sweat  on  the  hands  and  feet  Hemorrhage  from  the  stom- 
ach and  bowels.  Convulsions  with  dysuric  and  hydrophobic 
symptoms. 


LEADING  INDICATIONS. 


217 


stupor.    Symp- 

3,  with  desire  to 
vous  excitement 
of  the  carotids, 
ead.  Eed,  swol- 
3r  oscillating  pu- 
ed,  swollen  face, 
rning  and  throb- 
cold  water.  Ee- 
)  profuse.  Dry, 
)  back,  loins  and 
ind  without.     In 

on  as  if  sinking 
down  to  the  ueck 
m  motion.  Pain, 
otion.  Dark  red 
I  tongue.  Thick 
Jitter,  sour  taste, 
ir.  Fullness  and 
nausea  on  sitting 
hard,  rapid  pulse, 
in  warm  weather 

like  taste  in  the 
id  cutting  in  the 
sh  fluid.    Fain  in 

Gtreat  anxiety  and 
;,  scarcely  percep- 
f.    Cold,  clammy 

the  conjunctiva, 
rbid,  scanty  urine, 
ring  in  the  limbs; 
»e  from  the  stom- 
and  hydrophobic 


Carbo.  veg. — Great  restlessness;  icy  coldness  of  the  whole 
body.  Pale,  greenish-yellow  color  of  the  face;  hippocratic  coun- 
tenance. Pressive  headache  above  the  eyes.  Pupils  insensible 
to  light.  Severe  and  oft-repeated  nosebleed.  Dryness  and  raw- 
ness of  the  tip  of  the  tongue.  Sour,  rancid  eructations;  burning 
and  sensitiveness  in  the  epigastrium  with  vomiting  of  blood. 
Flatulence;  putrid,  cadaverous,  involuntary  evacuations.  Dark 
red,  bloody  urine.  Difficult  breathing;  desire  to  be  fanne<l. 
Weak,  small,  thread-like  pulse;  cyanosis.  Coldness  of  the 
breath;  cold  sweat  upon  the  limbs.     Ecchymoses. 

Cimicifuga. — Melancholy;  fear  of  death;  indifferent.  Exces- 
sive pain  behind  the  right  orbit.  Delirium,  dreams  about  ne- 
groes, devils,  etc.  Violent  pains  in  neck  and  back.  Excessive 
muscular  soreness.  Weakness,  trembling  and  sx)asmodic  action 
of  the  muscles.  Obstinate  sleeplessness;  waking  from  sleep 
with  a  start.     Alternate  tonic  and  clonic  spasms. 

Colocynth. — Dark  redness  of  the  face.  Colic  pains,  relieved 
by  pressure.  Frequent  urging  to  urinate  with  scanty  urination. 
Drawing  pain  in  the  right  thigh,  down  to  the  knee.  Cramp  in 
the  left  calf.  Tendency  to  cramp  in  all  muscles  of  the  body. 
Night  sweat  smelling  like  urine. 

Ci'otalns. — Delirium  with  open  eyes;  utter  apathy.  Intense 
headache;  with  red,  puffed  face.  Hemorrhage  from  all  the  ori- 
fices of  the  body.  Bloody  sweai  Deep  yellow  color  of  the  whole 
cutaneous  surface;  ecchymoses.  Coldness  of  the  skin.  Pulse 
either  slow  or  rapid  and  scarcely  perceptible.  Extreme  depres- 
sion of  vital  powers.  Weak,  hoarse,  rough  voice.  Sour,  acrid, 
eructations,  nausea;  bilious  or  bloody  vomiting;  bloody,  some- 
times involuntary  stools.     Painful  retention  of  urine. 

Cnprnm  acet. — Anguish  with  great  restlessness.  Convulsive 
and  restless  movements  of  the  eyes.  Blueness  of  the  face  and 
lips.  Gurgling  on  swallowing.  Excessive  nausea;  violent  vom- 
iting; with  pressure  on  the  stomach,  aggravated  by  touch  and 
motion;  bloody  vomiting.  Spasmodic  contraction  of  the  abdom- 
inal muscles.  Spasms  and  cramps  in  the  calves.    Clonic  spasma 

Eupatorium  perf. — Headache,  with  sore  feeling  internally. 
Soreness  of  the  eyeballs,  with  intolerance  of  lighi  Nausea 
with  retching  and  vomiting  of  bile.    Aching  pain  in  the  back, 


HMi 


Ji 


218 


LECTUnES  ON   FEVEBS. 


as  from  a  bruise.    The  bones  ache  as  if  broken.    Trembling  and 
nausea  from  tlie  slightest  motion. 

GelHeiiiium.— Dullness  of  the  mental  facxilties.  Vertigo  with 
loss  of  sight;  blurred  vision.  Fullness  of  the  head,  with  heat 
in  the  face  and  chilliness.  Heavy,  dull,  besotted  expression. 
Thick,  yellowish-white  coated  tong\ie;  difficult  deglutition;  fetid 
breath.  Frequent,  soft,  almost  imperceptible  pulse.  Trembling 
in  all  the  limbs.  Loss  of  muscular  power  in  the  legs.  Sleep- 
lessness; becomes  delirious  on  falling  asleep. 

Hyoscyamiis.— Delirium  and  restlessness.  Picking  at  the 
bedclothes.  Pressing  pain  in  tlie  forehead;  undulating  sensa- 
titm  in  the  brain.  Red  and  sparkling  eyes;  dilated  pupils.  Dark 
red  bloated  face.  Retching  and  vomiting;  hiccough;  tenderness 
over  the  epigastrium.  Involuntary  nocturnal  stools;  retention 
of  urine.  Convulsions;  sleeplessness  from  excessive  nervous 
excitement;  wakes  up  with  a  cry. 

Ipecac— Paleness  and  puffinessof  the  face;  blue  rings  around 
the  eyes.  Vertigo,  with  chilliness  and  pain  in  the  back  and  limbs. 
Distressing  nausea,  vomiting,  predominance  of  gastric  symptoms. 
Great  weakness  and  anxiety. 

Lachesis.— Nightly  delirium;  vertigo  in  the  morning  on  awak- 
ing.   Headache  over  the  eyes  and  in  the  occiput;  pressive  head- 
ache with  nausea.    Rush  of  blood  to  the  head  with  redness  of 
the  face;  bursting  pains  in  the  temples.    Yellowness  of  the  con- 
junctiva; dimness  of  vision;  black  flickering  before  the  eyes. 
Tongue,  mouth  and  lips  are  red,  dry  and  parched.     Tongue  i& 
heavy  and  trembles  when  protruded.    Neck  sensitive  to  the 
touch.   Sour  eructations ;  nausea  after  drinkng ;  stomach  sensitive 
to  pressure.    Foaming,  almost  black  urine.     Oppression  of  the 
chest  with  shortness  of  breath.    Irregular,  weak  pulse;  palpita- 
tion of  the  heart;  cramp-like  pain  in  the  precordial  region. 
Sleepiness  with  inability  to  sleep;  tossing  and  moving  during 
sleep;  symptoms  worse  after  sleep.     Great  physical  and  mental 
exhaustion;  attacks  of  suffocation.     Perspiration  at  night;  the 
sweat  stains  the  linen  yellow.    The  blood  is  dark  and  non-coag- 
ulable;  small  wounds  bleed  much,  sore  spots  have  a  dark  red, 
brownish  appearance. 

Lycopodium.— DepreFsion  of  spirits,  with  great  anxiety.  Press- 
ing or  tearing  frontal  headache;  worse  from  4  to  8  p.  M.  Yellow- 


LEADING  INDICATIONS. 


219 


bling  and 

rtigo  with 
with  heat  . 
xpression. 
tion;  fetid 
rrembling 
rs.    Sleep- 

ng  at  the 
king  sensa- 
pils.  Dark 
tenderness 
i;  retention 
ve  nervous 

ings  around 
a  and  limbs. 
B  symptoms. 

ng  on  nwak- 
essive  head- 
i  redness  oi 
of  the  con- 
•e  the  eyes. 
Tongue  is 
litive  to  the 
|ach  sensitive 
jssion  of  the 
ilse;  palpita- 
dial  region, 
►ving  during 
and  mental 
it  night;  the 
nd  non-coag- 
je  a  dark  red, 

^xiety.  Press- 
ji.  Yell'^w- 


ish-gray  color  of  the  face.  Gums  bleed  from  tbe  slightest  touch; 
vesicles  on  the  tongue.  Acrid  eructations;  pressure  and  heavi- 
ness in  the  stomach;  hiccough.  Flatulent  distension  of  the 
abdomen.  Severe  backache;  fiequeut  desire  to  urinate;  hem- 
orrhage from  the  kidneys  and  bladder.  Shortness  of  breath, 
especially  during  sleep;  soporous  sleep. 

MercuriuH. — Great  anxiety  and  re«<tle8sness;  weakness  of 
memory:  and  moroseness.  Vertigo  with  violent  headache;  pres- 
sive  pain  in  the  left  temple.  Eyes  red,  inflamed,  and  sensitive 
to  light,  especially  fire-light.  Fuffiness  of  the  face;  dirty  yellow 
skin.  Hemorrhage  from  the  gums;  fetid  odor  from  the  mouth. 
Tongue  swollen,  coated  white,  and  showing  the  imprints  of  the 
teeth;  profuse  salivation.  Begion  of  the  liver  swollen  and  sen- 
sitive to  pressure.  Violent  thirst,  with  vomiting  of  slime  and 
bilious  matter.  Dark  red,  turbid  urine.  Weakness  and  weari- 
ness in  all  the  limbs;  coldness  of  the  extremities.  Glandular 
swellings.    Perspiration  stains  the  linen  yellow. 

Nux  Tom. — Extreme  sensitiveness  to  external  impressions; 
great  anxiety.  Headache,  with  tension  in  the  forehead,  worse  in 
the  morning  before  opening  the  eyes.  Eyes  injected,  yellow,  and 
watery.  .Yellowness  of  the  skin;  paleness  or  yellowness  of  the 
face.  Heaviness  of  the  tongue  with  diflScult  speech;  dryness  of 
the  mouth;  accumulation  of  mucus  in  the  throat  Thirst  for 
beer  or  stimulating  drinks;  tension  and  fullness  in  the  epigastri- 
um; violent  hiccough;  bitter,  sour  eructations.  Contractions  of 
the  abdominal  muscles;  small,  slimy,  bilious  or  bloody  stools. 
Burning  pain  in  the  neck  of  the  bladder,  with  difficult  urination. 
Convulsions;  cramps  in  different  parts  of  the  body. 

Phosphorus. — Great  indisposition;  inability  to  think;  low 
muttering  delirium.  Dull,  pressive frontal  headache;  throbbing 
pain  in  the  temples.  Face  puffy,  and  of  a  yellowish  hue;  blue 
rings  around  the  eyes.  Dry,  red  or  black  tongue.  Constant 
nausea;  vomiting  of  food  and  of  blood,  mingled  with  bile  and 
mucus.  Oppression  and  burning  in  the  epigastrium.  Hemor- 
rhages from  various  orifices  of  the  body.  Hsematuria.  Ecchy^ 
moses.  PetechisB. 

Bhns  tox. — Anxiety  with  great  restlessness;  apprehensive, 
"with  inclination  to  weep.  Talkative  delirium,  or  coma  with  rat- 
tling respiration.    Dirty  yellow  color  of  the  skin;  sunken  face; 


It 


MiMiaiim— wwiniiiwiri»iniiimriiiiwi«jiTrrrTi""n'n "• 


<sao 


LECTURES  ON  FEVEB8. 


!r^K'rb.rnd  S*;  r  ^nt  Lt.e.ne.  ..d  .s.n« 
about.     SleeplessnesB. 

Tartar  emet.-Headache  as  from  a  band  compresBing  the 
Jehead  Red  or  white  and  pasty  tongue,  ^ontmuous  nausea  ' 
wTth  areat  anxkty;  intense  and  long-lasting  vomiting;  absence 
f  thC  Dark  mldish-brown,  turbid  urine;  scanty  unnat  on. 
CrlMrembling  pulse.  Great  weakness,  with  trembling 
of  the  whole  body.    Great  sleepiness. 

Terebinthina.-Headache  with  intense  pressure  and  fullness 
nUhe  head  Tongue  red,  smooth  and  glossy.  Vomiting  of  mu- 
1  bit  or  bloodf^evere  burning  pain  with  excessive  distension 

:rr\e'Srt;nr^^^^^^^^^^^  Pai- .i"  the  kidneys,  with 
bloody  urine.    Strangury.    Great  prostration. 

Veratrniii  alb.-Aniciety  and  oppression  of  spirits.    Vertigo 
wil  cold  perspiration  on  the  forehead;  coldness  and  pressure 
lu  L  vlex     Face  pale,  or  yellowish,  cold  and  sunken;  hippo- 
rat  c^^tenance.  E%  dull,  yellowish  and  ^^^^^^^^ 
,     11  uio^v  vinCTH     Drvnessof  the  mouth  ana  palate,  com 

l^'S"^  tt^diS  Bwdlowmg;  hic«.ugh     Violent, 

thirst,  especially  I  -ferine.    Difficult  respiration, 

perceptible  intermittent  pulse,    icy  comu  over-dosing 

feet.     Extreme  weakness  and  prostration.     After  over-aosing 

with  castor  oil. 

T«r.trlim  Tlr.-Seirere  fcontal  headache  with  vomiting; 
hJdlSjrpleeding  from  the  n.pa  of  the  nect  ^^^^J^Z 
•»iH,  flashed  lace  and  convulsive  twitchings  of  the  laual  mns 
le?  DryneSof  the  month  and  lips;  tongne  feels .s  J  scalded, 
and  is  red  in  the  middle  and  yellow  at  the  edges.  Violent  nan- 
::aa"d  vomiting  with  pain  in  the  epigastrium.    Cr«nps  of  the 


HYGIENIC  AND   DIETETIC  TREATMENT. 


221 


,f  the  throat, 
ictations  and 
Pressure  and 
Dark,  bi  own 
.  urine.  Ach- 
,8  and  tossing 

apressing  the 
inuoUB  nausea 
Iting;  absence 
^nty  urination, 
vith  trembling 

re  and  fullness 
omiting  o£  mu- 
isive  distension 
muco-purulent 
mmy  sweat,  all 
le  kidneys,  with 

pirits.    Vertigo 
IS  and  pressure 
sunken;  hippo- 
ery;  surrounded 
ind  palate;  cold- 
cough.    Violent, 
id  blood.     Great 
ish  or  yellowish, 
icult  respiration, 
Small,  scarcely 
)£  the  hands  and 
iter  over-dosing 

with  vomiting; 
c.  Intense  fever, 
,£  the  facial  mus- 
Eeels  as  if  scalded, 
es.  Violent  nau- 
CrampB  of  the 


extremities.     Coldness  of  the  whole  body, 
sions,  especially  in  children. 


Threatened  convul- 


HYOIENIC  AND  DIETETIC  TREATMENT. 

The  hygienic  and  dietetic  treatment  of  yellow  fever  is  almost 
as  essential  ns  is  the  medicinal.  The  sick-room  should  be  large, 
well  lighted  and  well  ventilated.  As  soon  as  the  first  symptoms 
of  the  disease  appear,  the  patient  should  be  put  to  bed  and  kept 
in  a  state  of  perfect  mental  and  boilily  rest.  One  or  two  trusty 
friends  may  be  selected  as  nurses,  but  all  unnecessary  visiting  or 
going  to  and  fro  in  the  sick-chamber  must  be  strictly  forbidden. 
Piatt's  chlorides,  thymol  or  some  other  disinfectant  should  be 
sprinkled  upon  the  bed  and  aboiit  the  room,  several  times  a  day. 

During  the  first  twenty-four  hours  if  the  temperature  exceeds 
lOl"  Fahr.,  the  cold  bath  may  be  used.  After  this  time  frequent 
sponging  of  the  body,  under  the  bedclothes,  with  whisky  and 
water  is  preferable.  In  the  beginning  of  the  disease  the  hot 
foot-bath  is  quieting  to  the  system  and  may  prove  advantageous. 
Copious  enemata  should  be  administered  at  the  outset,  every  four 
or  six  hours,  until  two  or  three  satisfactory  discharges  are  ob- 
tained. Broken  ice  held  in  the  mouth,  will  generally  allay  the 
distressing  thirst,  and  is  often  very  refreshing  to  the  feverish 
patient.  An  infusion  of  orange  leaves  is  a  standard  drink;  it 
has  a  soothing  and  slightly  diaphoretic  influence.  After  the 
third  or  fourth  day,  milk  and  lime  water  or  chicken  broth  may 
be  given  every  two  or  three  hours.  When  the  stomach  is  very 
irritable,  rectal  alimentation  should  be  resorted  to.  Daily  ene- 
mas tend  to  remove  the  intestinal  flatus  and  almost  always  re- 
lieve the  vomiting.  Hot  water  fomentations  are  of  service  when 
pains  in  the  bowels  appear,  and  are  excruciating  and  persistent. 
Lumbar  pain  and  threatened  urinary  suppression  may  be  re- 
lieved by  turpentine  stupea  Ice-water  injections  into  the  rectum 
are  sometimes  successful  in  relieving  urinary  retention,  but 
usually  this  is  best  accomplished  by  the  use  of  the  catheter. 

Stimulants  are  always  needed  in  collapse,  and  in  the  sinking 
spells  of  nervous  prostration  following  the  disappearance  of  the 
fever.  They  may  be  used  on  the  third  day  of  the  disease,  or 
earlier  if  indicated.  When  called  for,  tablespoonf nl  doses  of 
iced  champagne  or  teaspoonful  doses  of  brandy  may  be  admin> 
istered  every  hour.    When  the  stomach  is  very  irritable,  injec- 


222 


LECTURES  ON   FEVEllH. 


tions  of  boef-toa  aiul  brandy  must  be  given.  Later,  after  the 
irritability  of  the  stomach  has  dlBappeared,  milk-punch,  ale  or 
porter  will  prove  useful.  Indigestible  food  must  be  guarded 
against  for  some  time  after  convalescence  api>ears  to  be  fully 
established 


LECTURE  X\. 

Ccrcbro-Spiual  Povor. 

Definition.— Cerebro-Bpiuul  fever  muy  be  defined  as  ft  malig. 
nant,  noncontagious,  febrile  aflfectiou  of  indefinite  duration,  due 
to  an  unknown  external  specific  cause,  and  assuming  a  variety  of 
forms,  marked  by  local  manifestations  wliich  pertain  chiefly  to 
the  cerebro-spinal  axis,  usually  prevailing  in  general  or  limited 
epidemics.  It  is  characterized  by  sudden  invasion;  by  intense 
headache,  uncontrollable  vomiting,  and  painful  cimtraction  of 
the  post-cervical  muscles;  by  cutaneous  hypertesthesia,  and  fre- 
quently by  a  rash  mostly  herpetic  and  petechial;  by  active  de- 
lirium  alternating  with  stupor,  or  stupor  deepening  into  coma; 
and  by  bi-lateral  deafness,  great  nervous  depression  and  motor 
paralysis.  Nearly  half  the  cases  die,  and  mostly  from  failure  of 
the  respiratory  nerve  centers;  those  who  survive  three  days,  have 
a  fair  chance  for  recovery.  After  death,  constant  lesions  of  the 
pia  mater  of  the  brain  and  spinal  cord  are  found.  Relapses  are 
oommon. 

Synonyms — Epidemic  cerebro-spinal  meningitis.  Cerebro- 
flpinal  typhus.  Malignant  purpuric  fever.  Petechial  fever. 
Spotted  fever.    Congestive  fever.    Tetanoid  fever. 

History.— This  disease  doubtless  prevailed  in  Europe  as  early 
as  the  fourteenth  century,  but  was  erroneously  described  as  a 
variety  of  typhus  until  shortly  after  the  beginning  of  the  pres- 
ent century.  The  first  of  the  circumscribed  epidemics  which 
appeared  nearly  simultaneously  in  Europe  and  in  the  United 
States,  started  at  Geneva,  in  Switzerland,  in  1806,  and  at  Med- 

(223.) 


iijiLmiiwiii]iiiimi»wi.w 


224 


LKCTUUEH  ON   FEVEKH. 


field,  MiiHH.,  in  1H(X>.  For  ten  yo«irH  following  Uuh  ()utl>reiik,  it 
previiiliul  ttitiier  H|M)nulioally  or  in  limited  opideniicB  <>n  iNith 
oontinontH.  In  1H22  it  iip|)earod  in  VohouI,  Frnnce,  fin<l  in  IH23 
nt  Middl<>t«)wn,  Conn.,  hut  wuh  of  Hhort  duriition.  (lornmny  wrb 
vinited  for  the  firHt  tin>o  in  the  winti^r  of  1H22-23.  After  a  long 
interval  the  fever  aj^ain  appeared  in  Europe  in  the  early  part  of 
18;{7,  and  prevailed  every  year  thereafter,  till  IHoO,  in  many 
plnceH,  fnim  the  Mediterranean  to  the  Baltic  wa.  Between  1840 
and  1850  it  waH  epidemiu  in  nearly  all  the  HtatoH  uf  tluH  country 
from  the  gulf  coawt  to  the  Dominion  of  Canada.  From  185-t  to 
1861,  it  wan  epidemic  in  Hweden,  and  from  18;')9  to  18(>0  in  Nor- 
way. In  18(>(J  a  most  destructive  outbreak  appeared  in  England 
and  Ireland.  In  18(50  the  disease  reappeared  in  this  country, 
and  prevailed  with  great  intensity  among  the  tr(M)ps  during  the 
civil  war.  A  transient  epidemic  «)ccurred  in  Canathi  in  1870,  aiad 
it  prevailed  quite  extensively  in  Now  York.  8ince  1873  it  bas 
not  a])i)eared  here  as  an  epidemic.  It  has  never  appeared  within 
the  tro])ics.  The  greatest  number  of  epidemics  have  lasted  from 
three  to  six  months.  And  usually  the  fatality  is  in  inverse  ratio 
to  the  duration  of  the  epidemic.  Cerebro-spiual  fever  is  by  no 
means  limited  to  the  human  race.  On  the  contrary,  it  frequently 
becomes  epidemic  among  the  lower  animals. 

Etiology. — The  causes  of  this  disease  are  of  two  kinils:  ])re- 
disj>nshi(f  and  exciting. 

1.  The  prcdisj-Hmng  causes. — Age  being  the  most  prominent,, 
merits  first  mention  as  a  predisposing  cause.  The  fever  is  by 
far  the  most  common  in  the  first  two  decades  of  life;  the  liability 
being  greatest  after  seven  years  of  age.  The  death  rate  is  higher 
during  childhood  than  at  any  other  period.  After  middle  life 
there  is  nearly  an  immunity. 

The  sen  sons  exert  considerable  influence  upon  the  spread  of 
the  disea  '  Epidemics  occur  oftener  in  the  winter  and  spring 
than  dur]  ^  the  summer  months,  and  generally  low  tempera- 
tures are  favorable  to  the  existence  and  spread  of  the  fever 
Ix>i8on. 

Modes  of  life  have  much  to  do  with  the  development  and 
prevalence  of  the  fever.  It  occurs  largely  among  those  who  by 
reason  of  poverty  or  other  cause,  are  subjected  to  privations  un- 
der unfavorable    hygienic  conditions.      Damp,  over-crowded^ 


l 


n'liii'nM'Ulii 


KTIOLooy. 


22r> 


liH  outliroiik,  it 

ninic8  on  IhiIIi 

!e,  ntul  in  lH2a 

(Jorninny  was 

Aftor  11  long 

0  cnrly  part  of 
IMfiO,  in  nmny 

13etwet>n  1840 
jf  thin  country 

From  1854  to 
to  18(50  in  Nor- 
red  in  Englnnd 
u  this  country, 
ops  (luring  the 
till  in  1870,  ftiad 
ice  1873  it  bns 
ppeared  within 
ave  lasted  from 
in  inverse  ratio 

1  fever  is  by  no 
•y,  it  frequently 

two  kintls:  pre- 

tost  prominent,, 
The  fever  is  by 
fe;  the  liability 
h  rate  is  higher 
fter  middle  lif& 

>n  the  spread  of 
nter  and  spring 
y  low  tempera- 
id  of  the  fever 

ivelopment  and 
ig  those  who  by 
o  privations  un- 
,  over-crowded^ 


Imdly-vciiHlated,  and  uiicU'an  liabitationH,  eHiH>cially  favor  it. 
Invalids  mw  not  particularly  i)rJ"diHp<)H«>(l;  on  tho  oth.T  liiind, 
tlioHO  atliu-l  I  nro  fn'*|u<'Mtly  h.-altliy  and  robunt.  ()vi-r-\vork! 
oxi'itonuMit,  III  lital  and  InMlily  fatiguo,  cond»in<'d  with  iirogidar- 
ity  in  oatinj,',  ronderw  tho  nyHtt-ni  oxtronioly  Hnwccptibh'.  HfatlH- 
tics  show  that  active  miliiary  lif..  in  a  j)ow(Mful  cauHativc  condi- 
tion. 

2.  riio  cxcHhuj  cf/Mw.— The  exciting  canno  of  crobro-Hpinnl 
fover  rt-nmins  as  yet  unknown,  although  it  is  gunorally  Iw^iicved 
to  be  atnioHi)in*ric.  ZieniHHcn  Hpcakn  of  it  tw  a  morbific  gcini, 
which  prinuirily  arises  in  the  human  body,  and  infects  lieulthy 
neighbors  only  when  it  has  undergone  a  certain,  still  unknown, 
mo(lificati(m  by  means  of  cultivati<m  in  suitable  intermediate 
individuals.  The  theory  of  its  [jarasitic  origin  has  received 
considerable  iniiH>tus  from  the  recent  discovery  of  bacterial 
iovmn—Hchizomm-rlvs—in  tiie  pia  mater  after  death.  Cerebro- 
spinal fever  is  generally  believed  to  be  non-contagious. 

Varieties.— This  "chameleon-like  disorder,"  as  8tille  has 
been  pleased  to  term  it,  admits  of  classification  into  the  following 
four  varieties : — 

1.  The  simple  or  ordinary  varivUj,  which  represents  the  ;,'on. 
eral  course  of  the  disease,  and  which  will  be  fully  described  in 
the  clinical  history. 

2.  The  ahoriive  variety,  which  occurs  at  the  lieight  and  during 
the  decline  of  all  epidemics ;  is  characterized  by  headache,  spi- 
nal stiffness,  malaise,  and,  as  a  rule,  absence  of  fever;  and  rarely 
lasts  longer  than  from  five  to  seven  days. 

3.  The  intermittent  vanety,  which  is  characterized  by  inter- 
missions  and  exacerbations,  the  disease  assuming  the  quotidian 
or  tertian  type.  The  interraittency  frequently  lasts  for  weeks, 
and  suddenly  terminates  either  in  death  or«recovery. 

4.  The  fulminant  variety,  which  occurs  with  greatest  frequency 
at  the  beginning  of  epidemics,  and  which  generally  terminates 
in  death  within  a  few  hours.  In  this  fatal  form  of  the  disease, 
the  onset  is  sudden,  usually  with  a  violent,  shaking  chill.  Im- 
mediately, the  patient  becomes  oyanosed,  and  the  skin  cold  and 
shrunken.  There  is  contraction  of  the  neck,  and  purpuric 
blotches  appear  on  the  surface  of  the  body.  The  urine  is  scanty 
and  loaded  with  albumen.  The  respirations  are  slow  and  labored. 


,-r 


226 


LECTUIIES   ON  FEVEBS, 


nud  the  pulse  becomes  rapid  and  faint.     The  headache  alternates 
with  drowsiness,  and  rapidly  gives  way  to  coma  and  death. 

Clinical  History. — Cerebro-spinal  fever,  though  occasionally 
preceded  by  a  prodromal  stage,  of  from  h  few  hours  to  several 
days  durrtion,  marked  by  chilliness,  headache,  muscular  pains 
and  general  languor,  ordinarily  begins  abruptly  with  chilliness 
or  a  distinct  chill,  followed  immediately  by  pronounced  symp- 
toms. In  children  a  convulsion  frequently  takes  the  place  of 
the  chill.  The  patient  at  once  takes  to  the  bed,  is  restless  and 
complains  of  violent  headache,  vertigo,  and  vomiting,  especially 
on  rising,  with  slight  nausea.  During  the  intervals  of  vomiting 
a  sensation  of  depression  or  faintness  in  the  epigastrium  is  fre- 
quently experienced.  The  face  is  usually  pale  or  cyanotic,  the 
countenance  distressed,  the  conjunctiva  injected,  and  the  pupils 
abnormally  dilated.  Dragging  paiijs  are  soon  experienced  in  the 
neck,  along  the  spine,  and  in  one  or  both  extremities;  and  are 
rapidly  followed  by  tonic  contraction  of  the  post-cervical  muscles. 
At  times  this  muscular  contraction  extends  to  the  muscles  of  the 
trunk,  abdomen  and  lower  extremities.  The  patient  lies  with  the 
head  drawn  back,  the  spine  rigid,  straightened — orthotonos — 
or  curved— sometimes  into  complete  opisthotonos — and  with  the 
arms,  thighs,  and  legs  liexed.  The  entire  cutaneous  surface,  but 
more  especially  the  skin  of  the  face,  forehead  and  neck,  is  ex- 
tremely sensitive  to  touch  and  pressure.  Intense  sickening 
neuralgic  pains  in  the  chest  and  abdomen  frequently  occur. 
There  is  loss  of  taste,  and  the  tongue  is  covered  with  a  thin, 
whitish  fur;  exceptionally  it  is  dry  and  brownish.  In  addition, 
there  is  extreme  sensitiveness  to  light  and  noise.  As  the  disease 
progresses  the  intense  headache  aikmates  with  or  gives  way  to 
passive  or  active  delirium,  which  in  a  short  time  passes  into 
coma. 

The  fever  is  atypical  and  irregular,  aud  usually  reaches  its 
maximum — 105"  Fahr.  to  107°  Fahr. — in  the  first  days  of  the 
disease.  The  temperature  of  the  extremities  is  extremely  varia- 
ble; more  so  than  in  any  other  affection.  The  pulse  may  be 
either  normal,  rapid,  or  only  moderately  quickened.  Its  remark- 
able variation  as  to  frequency  and  tension  is  almost  characteristic. 
The  respirations  are  at  lirst  quickened;  later  they  may  become 
intermittent,  sighing,  and  irregular.    In  fatal  cases  they  may 


.'Avn^  ^'.jiaKM.jj^aiwyg  ■ 


ANALYSIS   OF  CHART. 


227 


dache  alternates 
and  death. 

ugh  occasionally 
hours  to  several 
,  muscular  pains 
[y  with  chilliness 
•onounced  symp- 
kes  the  place  of 
d,  is  restless  and 
aaiting,  especially 
rvals  of  vomiting 
pigastrium  is  f  re- 
)  or  cyanotic,  the 
id,  and  the  pupils 
experienced  in  the 
remities;  and  are 
t-cervical  muscles. 
the  muscles  of  the 
itient  lies  with  the 
aed — orthotonos — 
ncs— and  with  the 
neous  surface,  but 
i  and  neck,  is  ex- 
Intense  sickening 
frequently  occur, 
vered  with  a  thin, 
ush.     In  addition, 
se.     As  the  disease 
ith  or  gives  way  to 
time  passes  into 

isually  reaches  its 
first  days  of  the 
is  extremely  varia- 
Che  pulse  may  be 
ened.  Its  remark- 
nost  characteristic, 
they  may  become 
al  cases  they  may 


present  that  alternation  of  respiration",  with  respiratory  pauses, 
known  as  Cheyne-Stokes  respiration. 

After  the  first  few  days,  herpetic  spots  are  apt  to  appear  upon 
the  face,  especially  along  the  branches  of  the  fifth  pair  of  nerves; 
while  petechial,  erythematous  and  urticarial  eruptions  are  not 
uncommon.  The  bowels  are  generally  constipated;  towards  the 
close  of  the  attack,  diarrhea  and  involuntary  evacuations  may 
occur.  All  the  symptoms  develop  rapidly,  and  reach  their  full 
intensity  from  the  third  to  the  sixth  day.  After  the  disease  has 
lasted  some  time  the  patient  may  pass  into  that  condition  termed 
the  typhoid  state;  a  condition  usually  marked  by  stupor  or  re- 
mitting delirium,  a  dry,  cracked  tongue,  sordes  on  the  lips  and 
teeth,  a  small,  rapid  pulse,  and  involuntary  evacuations. 

If  the  attack  is  to  terminate  fatally,  the  symptoms  of  nervous 
excitation  yield  to  those  of  depression.  The  rigidity  disappears; 
the  pulse  becomes  rapid,  small  and  scarcely  perceptible;  and  the 
temperature  rises  to  105°  Fahr.  or  108°  Fahr.  The  patient 
passes  into  a  state  of  stupor;  convulsive  muscular  movements  or 
paralysis  occur;  the  stupor  deepens  into  coma,  and  death  super- 
Tenes. 

In  favorable  cases,  the  symptoms  of  depression  are  less  marked 
and  of  shorter  duration.  Early  in  the  disease  the  vomiting 
«eases,  the  back  and  head  pains  subside;  and  the  rigidity  disap- 
,  pears.  The  strength  slowly  returns,  and  the  patient  enters  upon 
a  gradual,  somewhat  protracted  convalescence.  A  recurrence  of 
"vertigo  and  headache,  during  convalescence,  is  of  serious  im- 
port, and,  when  associated  with  vomiting  and  convulsions,  points 
to  the  development  of  hydrocephalus. 

ANALYSIS  OF  CHART. 

The  Nervous  System. — The  chill  which  ushers  in  the  attack 
may  be  nothing  more  than  a  chilly  sensation;  usually  it  is  pro- 
nounced, at  times  violent  and  oft  repeated,  and  may  last  from 
one  to  two  hours.  In  the  majority  of  instances  it  appears  ab- 
ruptly, in  the  evening,  during  the  night,  or  on  rising  in  the 
morning. 

Headache  is  one  of  the  earlier  and  more  persistent  symptoms 
of  the  disease.  It  is  generally  severe  in  character,  and  gives 
rise  to  great  restlessness  and  anxiety.  It  may  be  located  in  the 
forehead,  occiput,  temples,  or  extend  over  the  whole  head,  and 
is  of  a  beating,  boring,  stabbing  character.     As  it  usually  con- 


■MRm 


■t 


jr 


228 


LECTURES  ON   FEVERS. 


CHAKT  X.— Cerebrospinal  Fever. 

Nature: 

Epidemic.                               Non-contagious. 

Vurlettes: 

Simple: 

Abortive: 

Intermitt- 
ent. 

Fulminant: 

Initial  Symptoina: 

Vomiting  on  ris- 

ng.    Chill.    Pros 

tratlon. 

Sleepiness. 

Vertigo. 
Prost'tion 

Violent  eh  III. 
Vomitinif.  Pros- 
tration. 

Duration : 

1  to  3  weeks. 

.I  to  7  days. 

Several 
weeks. 

13  hours  to  3  days. 

Head: 

Headache  on  the 
first  day. 

Headache. 

X  B 

q 

Si 

1  1 
S-  S 

B     O 

«     m 

S     0 

§   3 

C  13 

8.  o 

1  ^ 

1 

Intense  headache 

Nervous  System: 

Restlegsncss.    De- 
lirium. 

Sleeplessness. 

Delirium. 

Coma.Convul«ions 

Collapse 

Hplne: 

HU/tdity  of  poat- 

eervical  muKcles. 

Ortbotonos. 

Stiffness  in  neck 
and  spine. 

Contraction  of 
neck. 

EAcremities: 

RigUiitii. 

Neuralgic  pains. 

Paralysis 

Stiffness  and 
Contractions. 

Muwular  riffiaity 
Paralysis. 

Tongue: 

Coated  white. 

moist;    later,  dry 

and  brown. 

Coated  white. 
Moist. 

Dry  and  brown 
Sordes. 

Stomach: 

Thirst.  Anorexia. 
Bilious  vomiting. 

Vomiting. 

Nausea  and 
vomiting. 

Bowels: 

Neuralgic  pains. 
Constipated. 

Constipated. 

Neuralgic  pains. 
Involuntary  evac- 
uations 

Skin: 

Hypercesthegia. 
Herpes.  Petechltc- 

Hyperresthesio. 

F'/perceMhenia 
Pu  rpuric  blotches. 
aiiperfici.il  e.inerene. 

Paee: 

Usually  pale. 

Pale. 

Shrunken,  livid. 

Eyes: 

Photophobia. 
Conjunctiva  in- 
jected Strabismus 

Conjundtlva  red- 
dened. 

Deep-sunkeu  eyes. 
Purulent  choroid- 
itis. 

Ears: 

Humming  and 

ringing.  Bi-late»l 

deafness. 

Humming  in  ears. 

Deafness. 

Temperature: 

B9.5-'  to  104"  Fahr. 
Atypical. 

Seldom  above 
normal. 

105"  to  107"  Fahr. 

Pulse: 

Extremely  varia- 
ble.    40  to  160. 

Variable. 

Variable. 
Weak  and  rapid. 

Respiration: 

Accelerated. 
Irregular. 

Easy. 

Slow  and  labored 
Arythmic. 

Urine: 

Increased. 

Increased. 

Scanty.    Albu- 
minuria. 

Convalescence: 

Irregular  and  un- 
certain. 

Early. 

Seldom  attained. 

Complications: 

Croupotu  pneumonia.    Endo  and  peri-carditls.    Pieuritis. 
Parotitis.    Intestinal  catarrh. 

Sequela: 

Debility.    Weakness  of  memory.    Local  paralysis 
Deafness.   Hydrocephalus, 

Prognosis: 

The  mortality  veries  from  TO  to  75  per  cent. 

Lesion: 

Fibrinous  or  purulent  exudation  in  meshes  of  cercbro-spinal 
pia  mater. 

ii.j_jijn.'tLai.tu 


ANALTSIS  OF  CHART. 


229 


tinues  throughout  tho  attack,  its  cessation,  unless  followed  by 
coma  or  collapse,  is  a  most  favorable  indication.  In  a  large  per- 
centage of  cases,  mental  or  bodily  fatigue  will  bring  on  severe 
headaches  long  after  convalescence  has  been  fully  established. 

Vertigo  occurs  as  one  of  the  prodromal  symptoms,  and  is  fre- 
quently associated  with  the  headache.  Recurring  during  con- 
valescence, vertigo  and  headache,  especially  when  associated 
Tvith  vomiting  and  convulsions,  are  of  unfavorable  omen,  as 
indicating  the  development  of  hydrocephalus. 

The  pupils  maj'^  be  contracted  at  the  outset  and  dilated  at  the 
close  of  an  attack;  not  unfrequently  they  diflfer  in  size.  There 
is  almost  constant  photophobia;  occasionally,  nystagmus  and 
transitoiy  strabismus  are  observed.  Conjunctivitis  is  of  fre- 
quent occurrence.  When  it  is  severe  there  is  marked  chemosis, 
with  opacity  and  ulceration  of  the  cornea.  At  times,  in  conse- 
quence of  severe  suppurative  irido-choroiditis  or  optic  neuritis, 
there  is  permanent  and  complete  loss  of  sight. 

The  ear  symptoms,  which  are  usually  bi-lateral,  consist  of  pain, 
humming  and  ringing  in  the  ears,  followed  by  partial  or  com- 
plete, temporary  or  permanent  deafness.  They  are  due  either 
to  a  catarrhal  or  purulent  inflammation  of  the  middle  ear,  or  to 
suppurative  inflammation  of  the  labyrinth.  " 

Delirium,  often  transient,  at  times  alternating  with  periods  of 
stupor,  is  present  in  almost  all  severe  cases  after  the  second  or 
third  day.  In  mild  cases  it  is  slight,  and  occurs  mostly  at  night; 
in  fatal  cases  it  becomes  ontinuous,  and  finally  passes  into  the 
coma  which  precedes  death.  In  the  worst  forms,  coma  may  occur 
without  the  intervention  of  delirium. 

Convulsions  are  not  infrequently  met  with  in  children,  replac- 
ing the  initial  chill.  They  vary  in  degree  from  simple  muscular 
iwitchings,  to  violent  epileptiform  seizures.  If  long  continued, 
they  render  the  prognosis  unfavorable. 

Paralysis,  located  in  the  muscles  of  deglutition  and  articula- 
tion, or  affecting  one  or  both  extremities,  occurs  in  a  small  pro- 
portion of  cases.  It  usually  develops  towards  the  close  of  the 
disease,  and  may  either  disappear  in  a  few  days  or  last  for  years. 

Stiffness  of  the  neck,  caused  by  contraction  of  the  deep  cervi- 
cal muscles,  is  a  marked  characteristic.  It  appears  mostly  be- 
tween the  second  and  fifth  days,  and  lingers  far  into  convalescence. 
It  varies  greatly  in  degree,  from  a  slight  stiflhess  noticeable  only 


I 


|l 


280 


LECTURES  ON  FEVERS. 


when  attempting  to  flex  the  liead,  to  a  contraction  so  great  that 
the  vertex  is  drawn  down  between  the  shoulders,  at  almost  a 
right  angle  with  the  spine.  In  the  worst  cases  swallowing  i» 
rendered  extremely  difficult  and  painful.  In  exceptional  case* 
this  stiffness  of  the  neck  may  be  absent.  It  is  generally  regarded 
as  a  reflex  contraction  due  to  inflammation  of  the  pia  mater  of 
the  medulla,  and  of  the  posterior  columns  and  roots  of  the  cer- 
vical portion  of  the  cord. 

Contraction  of  the  other  erector  muscles  of  the  spine  is  present 
in  a  large  proportion  of  cases,  and  varies  in  degree  from  a  mere 
stiffness,  and  straightening  of  the  spine  (orthotonos),  to  a  draw- 
ing of  the  trunk  into  so  distinct  an  arch  that  the  body  rests  only 
upon  the  occiput  and  heels  (opisthotonos).  Orthotonos  is  of 
frequent  occurrence,  while  complete  tetanoid  opisthotonos  and 
pleurosthotonos  (unilateral  contraction  of  the  spinal  muscles) 
are  extremely  rare.  The  duration  of  the  contraction  is  very  va- 
riable. In  favorable  cases  it  disappears  in  from  a  few  days  to 
two  or  three  weeks;  not  unfrequently  it  continues  from  four  to 
six  weeks.  Trismus  has  been  observed  only  in  patients  who  are 
dangerously  ill  and  comatose,  and  is  an  unfavorable  symptom. 
Stiffness  and  contraction  of  the  muscles  cf  the  extremities  is 

not  uncommon^  present. 

Fia.  14. 


Attitude  of  the  Patient  in  Severe  Cerebro-spinal  Fever  (After  Smith). 
In  consequence  of  these  muscular  rigidities  the  usual  attitude 
of  the  patient  in  bed  (Fig.  14),  is  with  the  head  drawn  back,  the 
spine  straightened  or  arched  forward,  the  forearms  flexed  upon 
the  arms,  the  legs  upon  the  thighs,  and  the  thighs  drawn  up 
upon  the  abdomen. 


ANALYSIS   OF  CHAHT. 


231 


on  BO  great  that 
iers,  at  almost  a 
es  Bwallowiug  is 
exceptional  case* 
luerally  regarded 
the  pia  mater  ul 
roots  of  the  cer- 

S2yine  is  present 
^ee  from  a  mere 
onos),  to  a  draw- 
3  body  rests  only 
Orthotonos  is  of 
opisthotonos  and 

spinal  muscles) 
iction  is  very  va- 
»m  a  few  days  to 
les  from  four  to 
patients  who  are 
)rable  symptom. 
ke  extremities  is 


jr  (After  Smith), 
he  usual  attitude 
I  drawn  back,  the 
arms  flexed  upon 
thighs  drawn  up 


Pains  in  the  spine  (rachialgia),  iwck,  loins  and  legs,  occurring 
in  exacerbations  and  remissions,  are  frequent  symptoms.  They 
vary  considerably  in  intensity  and  duration,  and  are  often  inten- 
sified by  attempted  movements.  Inflammation  of  the  wrist-joints 
is  occasionally  met  with. 

The  Cutaneous  Surface. — Hyjwrcpsthesia  of  the  skin  though 
not  a  constant  symptom,  is  thoroughly  characteristic  when  pres- 
ent. It  usually  appears  as  early  as  the  second  or  third  day,  and 
is  most  marked  on  the  anterior  surface  of  the  lower  extremities. 
It  is  often  so  severe,  that  the  simple  movement  of  the  limbs,  the 
mere  touching  of  the  surface  of  the  body,  or  even  the  slightest 
shaking  of  the  bed,  will  give  rise  to  expressions  of  pain  and 
suffering. 

Cutaneous  eruptions  developing  symmetrically  are  oftener 
associated  with  cerebro-spinal  fever,  in  this  country  than  in  Eu- 
rope. Of  these  herpes,  commencing  usually  about  the  second  or 
third  day,  upon  the  lips  and  extending  over  the  face,  and  at  times 
appearing  upon  the  trunk  and  e:^tremities,is  the  most  common. 

PeiechicB  and  ecchymoses  are  not  infrequent  manifestations. 
When  present,  they  produce  a  more  or  less  distinct,  widely  dif- 
fused mottling  of  the  whole  surface.  Other  forms  of  eruption 
occasionally  observed  are,  roseola,  erythema,  urticaria,  erysipe- 
las and  sudamina.  Sometimes  a  patient  presents  three  or  four 
separate  forms  of  cutaneous  eruptions. 

The  Temperature. — The  course  of  the  fever  is  irregular  and 
the  temperature  curve  is  atypical.  It  is  apt  to  have  attained 
considerable  elevation  as  early  as  the  second  or  third  day.  After 
the  disease  has  become  fully  established  its  average  range  in 
adults  is  from  100.5°  Fahr.  to  104°  Fahr. ;  in  children  it  is  some- 
what higher.  Exacerbations  of  pain  may  cause  a  rise  of  two  or 
three  degrees.  In  rapidly  fatal  cases  it  may  reach  107°  Fahr.  or 
even  110°  Fahr.,  as  death  approaches.  Defervescence,  rarely 
rapid,  usually  takes  place  by  a  gradual  fall  (lysis);  a  rapid  fall 
almost  invariably  ushers  in  collapse  and  death.  The  difference 
between  the  morning  and  evening  temperatures  is  neither  as 
marked  nor  as  constant  as  in  most  other  fevers. 
Wunderlich  distinguishes  three  special  fever  courses: — 
1.  "  In  some  very  severe  and  rapidly  fatal  cases  the  tempera- 
ture, though  not  invariably  very  high  at  the  beginning  of  the 


mjHmmMibuim 


232 


LECTUHE8   ON   FEVERS. 


disease,  reaches  very  striking  heights  in  the  briefest  time.  It 
remains  high,  rising  even  higher  at  the  approach  of  death,  till 
in  the  very  moment  of  death  it  may  attain  107.6°  Fahr.  or  more. 
In  one  of  his  cases  it  reached  110.7°  Fahr.  It  may  rise  some 
tenths  of  a  degree  after  death.  In  some  fatal  cases  the  temper- 
ature may  remain  very  moderate  for  some  time,  and  rise  rapidly  . 
and  with  abruptness  at  the  close  of  life. 

2.  "  On  the  other  hand,  relatively  mild  cases  exhibit  a  fever  of 
only  short  duration,  although  there  are  sometimes  considerable 
elevations  of  temperature  and  often  an  interrupted  course.  Ke- 
covery  does  not  take  place  by  crisis,  but  happens  ratlier  with  a 
remittent  defervescence  (lysis).  Here  and  there  cases  occur 
which,  after  defervescing  and  apparently  almost  recovering,  re- 
lapse all  at  once  with  a  rapid  rise  of  temperature  and  run  a 
course  like  those  marked  (1). 

3.  "  In  contrast  with  these  brief  courses  of  fever  with  either 
very  severe  or  slight  character,  we  find  cases  which  are  more  or 
less  protracted.  The  height  of  the  temperature  in  these  may 
be  varied,  and  indeed  exhibit  manifold  changes  in  the  very  same 
case,  though  this  chiefly  depends  upon  the  varied  complications 
which  supervene  in  the  shape  of  bronchial,  pulmonary  and  in- 
testinal affections,  and  affections  of  serous  membranes." 

The  Circulatory  and  Respiratory  Systems.  -T/te  pulse  is 
extremely  variable,  and  bears  no  constant  relaf  m  to  either  the 
height  of  the  fever,  or  the  gravity  of  the  other  symptoms.  As 
a  rule,  especially  in  children,  it  rises  with  the  onset  of  the  fever, 
and  in  fatal  cases  is  often  so  rapid  that  it  cannot  be  counted; 
occasionally  it  remains  normal;  and  but  rarely  it  is  retarded. 
Its  most  constant  character  is  its  variations  in  rapidHy.  It  may 
show  a  difference  of  thirty  or  forty  beats  in  a  few  hours;  and 
sometimes  even  within  r  f'3w  minutes  it  may  vary  twenty  or 
thirty  beats.  Continued  if.pidity  is  to  be  regarded  as  unfavor- 
able. 

The  respirations  sometimes  remain  undisturbed  in  mild  cases. 
They  are  usually  sighing,  labored  and  interrupted  in  grave  cases. 
Tne  Cheyne-Stokes  respiration  is  supposed  to  be  due  to  pressure 
upon,  or  oedema  of  the  medulla  oblongata.  Catarrhal  affections 
of  the  upper  air  passages  are  not  uncommon. 

The  Digestive  Tract. — The  tongue  is  moist  and  coated  with 


MOBBID  ANATOMY. 


233 


?fest  time.  It 
1  of  death,  till 
Fahr.  or  more, 
may  rise  some 
es  the  temper- 
ed rise  rapidly  , 

[libit  a  fever  of 
IS  considerable 
d  course.  Re- 
}  ratlier  with  a 
re  cases  occur 
recovering,  re- 
;ure  and  run  a 

ver  with  either 
ich  are  more  or 
i  in  these  may 
a  the  very  same 
I  complications 
monary  and  in- 
•ranes." 

, — TJie  pulse  is 
m  to  either  the 
symptoms.  As 
set  of  the  fever, 
lot  be  counted; 
/  it  is  retarded. 
ipidUy.  It  mny 
few  hours;  and 
vary  twenty  or 
led  as  unfavor- 
ed in  mild  cases, 
i  in  grave  cases. 
)  due  to  pressure 
arrhal  affections 

and  coated  with 


n  whitish  fur  at  the  beginning  of  the  fever  and  during  deferves- 
cence. At  the  height  of  the  disease  it  may  become  dry  and 
brown.  The  teeth  and  lips  are  frequently  covered  with  sordes. 
VamUing  is  an  early  and  frequently  recurring  symptom.  It 
may  occur  without  previous  nausea,  and  is  excited  by  movement, 
particularly  by  rising.  Thirst  and  anorexia  are  strongly  marked. 
Constipation  is  the  rule.  Jaundice  is  present  in  a  small  number 
of  cases.  Parotitis  is  considered  a  possible,  but  infrequent  ac- 
cident of  the  disease. 

The  urine  is  increased  in  quantity  and  loaded  with  urates; 
occasionally  it  contains  a  moderate  amount  ot  albumen.  Polyu- 
ria is  frequently  observed,  especially  in  children. 

Complications  and  Sequels. — The  complications  of  cerebro- 
spinal fever  vary  in  different  epidemics,  and  at  different  stages 
of  the  same  epidemic.  The  most  frequent  are:  catarrhal  and 
croupous  pneumonia,  bronchial  catarrh,  pleuritis,  endo-carditis, 
peri-carditis,  intestinal  catarrh,  choroiditis  with  coiisecutive  de- 
tachment of  the  retina,  and  purulent  inflammation  of  the  laby- 
rinth and  tympanum.  The  more  important  sequels  are:  deafness, 
derangements  of  vision,  general  debility,  boils  and  carbuncles, 
paralysis,  weakness  of  memory,  and  chronic  hydrocephalus. 

Morbid  Anatomy. — Tlie  lesions  of  cerebro-spinal  fever,  which 
are  due  in  part  to  the  direct  action  of  the  morbific  agent  upon 
the  blood,  and  in  part  to  the  inflammation,  are  quite  constant 
and  vary  only  in  the  degree  of  their  development.  The  hlood 
contains  more  fibrin  than  normal,  the  amount  varying  according 
to  the  extent  of  the  inflammatidn.  In  malignant  cases  it  is 
usually  dark  and  fluid,  and  contains  a  few  dark  and  soft  clots. 
Bubbles  of  gas  have  been  observed  occasionally  in  the  large 
vossels  and  in  the  cavities  of  the  heart,  a  few  hours  after  death. 
The  heart  is  often  flabby,  and  exhibits  changes  due  to  granular 
degeneration.  The  pericardium  is  sometimes  inflamed,  and  cov- 
ered with  a  purulent  exudation;  recent  endocarditis  is  rarely 
observed.  The  lungs,  in  a  certain  proportion  of  cases,  exhibit 
changes,  such  as  hypersemia,  oedema,  patches  of  atelectasis  as  a 
result  of  capillary  bronchitis,  and  infiltrations  of  catarrhal  and 
less  frequently  of  croupous  pneiimonia.  Serous  transudations, 
sometimes  blood-stained,  occasionally  occur  in  the  pleural  and 
other  serous  cavities.  ■ 


tjiiiiiirmi 


HiriMnbftiaimwiliirfiii 


w-jrth<>nr>rt.-oiiT 


satSn'iMdaaf^ 


234 


LECTUBE8  ON   FEVERS. 


The  hrni'n  and  the  mcninfjrs  nre  intensely  congested  in  cnseg 
which  are  Hjjeedily  fatal.  The  cranial  sinuses  are  engorged  with 
dark  fluid  bloo<l,  containing  soft  post-mortem  clots,  or  firm 
thrombi.  The  arachnoid  membrane  may  remain  unchanged  in 
rapidly  progressing  cases;  it  may  appear  hypenemic  and  blood- 
stained, or  dry,  lustreless  and  opaque;  occasionally,  as  after  pro- 
longed illness,  it  becomes  rough  and  thickened.  The  jna  mater* 
which  is  the  seat  of  the  primary  inflammation,  is  for  the  first 
few  hours  hypertemic  and  adherent  to  the  surface  of  the  brain. 
After  the  second  or  third  day,  a  yellowish  or  greenish,  butter- 
like exudation,  consisting  mainly  of  fibrin,  mucine,  pus-cells  and 
free  granules,  and  varying  from  one  to  four  lines  in  thickness,  is 
found  to  occupy  the  sub-arachnoid  space.  The  exudation  is  most 
abundant  in  the  fissures  and  depressions  along  the  course  of  the 
vessels,  upon  and  around  the  optic  commissure,  and  also  ui)on  the 
pons  and  medulla  oblongata.  In  cases  of  great  severity  the  ex- 
udation of  fibrin  and  pus  may  occur  over  nearly  every  i)art  of 
the  cerebral  surface.  The  amount  of  serous  exudation  varies 
greatly  in  different  cases;  it  may  be  so  small  as  to  scarcely  at- 
tract attention;  or  it  maybe  so  large,  in  children,  as  to  cause  the 
head  to  present  all  the  appearances  of  ordinary  congenital  hy- 
drocephalus. The  brain  substance  is  frequently  congested,  and 
localized  cerebral  softening  is  not  uncommon.  The  ventricles, 
especially  in  protracted  cases,  are  found  to  contain  more  or  less 
turbid  serum,  and  at  times  pus.  The  membranes  of  the  cord 
present  changes  similar  to  those  of  the'  meninges  of  the  brain. 
The  pia  mater  is  roughened  and  thickened,  and  is  intimately  ad- 
herent to  the  cord.  The  exudation  appears  first  as  cloudy  serum, 
then  as  bands  of  fibrino-pus,  and  lastly  as  thick  layers  of  pus. 
It  is  seated  mostly  on  the  posterior  surface  of  the  cord,  and  is 
most  abundant  in  the  lumbar  region.  The  substance  of  the  cord 
may  present  changes  similar  .to  those  observed  in  the  encepha- 
lon,  such  as  hyperaemia,  serous  infiltration,  and  softening. 

The  muscles,  especially  those  extending  along  the  spinal  col- 
umn, are  found  to  have  undergone  granular  degeneration.  The 
kidneys  are,  as  a  rule,    congested;    at   times  the  tubules  are 

*The  changes  in  the  pia  mater  may  possibly  be  due  to  certain  schizomyeeteay 
which  finding  in  it  their  necessary  nourishment,  cause  by  their  development 
nnd  growth  such  chemical  changes  that  the  walls  of  the  capillaries  of  the  pia 
become  altered  in  structure.  * 


irMWMW 


DIFFERENTIAL   DIAGNOSIS. 


235 


igested  in  cnses 
i  engorged  with 
clots,  or  firm 
n  unchauged  in 
jmic  and  blood- 
ly,  as  after  pro- 
The  j)ia  inaier* 
is  for  the  first 
cfc  of  the  brain, 
reenish,  butter- 
le,  pus-cells  and 

in  thickness,  is 
tudation  is  most 
lie  course  of  tlie 
nd  also  ui)on  the 
severity  the  ex- 
ly  every  part  of 
xudation  varies 
I  to  scarcely  at- 
,  as  to  cause  the 
r  congenital  hy- 
yr  congested,  and 

The  ventricles, 
ftin  more  or  less 
jnes  of  the  cord 
res  of  the  brain. 
is  intimately  ad- 
as  cloudy  serum, 
k  layers  of  pus. 
the  cord,  and  is 
tance  of  the  cord 
.  in  the  encepha- 
softening. 
;  the  spinal  col- 
;eneration.     The 

the  tubules  are 

lertain  gchizomycetes, 
y  their  development 
capillaries  of  the  pia 


blocked  with  fat  granules  and  fibrinous  casts.  Emudniion  is 
strongly  marked,  especially  in  protracted  cases.  Post-vioricm 
rigidity  is  usually  marked  and  of  long  duration.  The  skin  dis- 
plays herpetic  crusts  and  petechial  stains;  more  or  less  extensive 
and  deep  disoolorations  of  the  dependent  parts  of  the  body  rap- 
idly appear. 

Diirerential  DiagnoHis. — The  diagnosis  of  cerebro-spinal  fe- 
ver is  usually  attended  with  but  little  difficulty  during  the  prev- 
alence of  epidemics.  It  is,  however,  far  from  easy  wben  sporadic 
cases  occur,  either  within  the  limits,  or  at  the  beginning  of  an 
epidemic,  or  when  very  young  infants  are  attacked,  or  when  it 
develops  as  an  intercurrent  affection  in  the  course  of  other 
acute  diseases  such  as  croupous  pneumonia  and  typhoid  fever. 
Of  diagnostic  importance  are,  early  in  the  disease,  the  sudden 
onset  of  the  symptoms,  the  headache,  the  vomiting,  the  pains  in  the 
neck,  spine  and  calves  of  the  legs,  the  stiffness  of  the  cervical  and 
spinal  muscles,  the  retraction  of  the  head,  and  the  general  cuta- 
neous hyperesthesia;  and  later,  the  herpes,  the  restlessness  and 
delirium,  the  tetanic  spasms,  the  irregular  temperature  and  the 
variable  pulse. 

It  may  be  simulated  by  tuberculous  basilar  meningitis,  typhus 
fever,  typhoid  fever,  scarlet  fever,  pernicious  fever,  masked, 
small-pox  and  tetanus. 

Tuberculous  basilar  meningitis  is  distinguished  by  its  gradual 
approach,  and  slow  course,  and  by  its  generally  appearing  in 
patients  of  a  scrofulous  or  tuberculous  diathesis.  It  presents  no 
characteristic  cutaneous  eruption;  but  when  the  finger  is  drawn 
across  the  skin  of  the  forehead  it  leaves  a  vivid  red  mark.  The 
delirium  is  usually  transitory,  and  there  may  be  slight  temporary 
paralysis  as  shown  in  imperfect  co-ordination  of  muscular  move- 
ments, but  no  tetanic  spasms.  The  paralysis  may  affect  the  op- 
tic commisure  and  oculo-motor  tracts.  Ophthalmoscopic  ex- 
amination will  reveal,  more  especially  when  general  tubercular 
disease  exists,  tubercles  of  the  choroid  with  neuro-retinitis. 
When  tubercular  meningitis  attacks  the  convexity  there  is  a  con- 
stant convulsive  condition,  moderate  force,  and  very  variable 
pulse. 

Typhus  fever  and  typhoid  fever  present  well-marked  points 
of  contrast  with  cerebro-spinal  fever,  which,  for  the  purposes  of 
differentiation,  may  be  arranged  in  tabular  form  as  follows: — 


■ 


taawiw 


J 


230 


LECTURES  ON  FEVERS. 


TYl'Ill'8  FRVEB. 

An  vpidi'inic  iliHeasc 
Highly  coiitagiouH. 
Onset  Hiiildoii' 
Occurs  at  nil  ages. 
Ocrura  nt  ull  scumjiis. 
Durutiou,  about  14  days. 

Defervescence,  critical    01 

by  rapid  lyaiii. 
Kelapscfl,  rare. 
Countenance,  dusky-red. 

Pupils  equal  nnd  con 
traded 

StrabiHuius  rare. 

Dcufuess  seldom  perma- 
nent. 

Skin  emits  an  ammoniacal 
odor. 

Mulberry  rash,   rarely   ab- 
sent. 
Appears  on  5th  or  6th  day. 
Ecchynioses,  rare, 
Headache,  dull  or  heavy. 

Delirium     rarely     absent. 

Begins   at    end   of  first 

week. 
Temperature  range,  typi 

Cttl. 

Pulse,  soft;  100  to  140. 

Vomiting,  rare. 

Tetanic  spasms  absent. 
Pains,  dull  and  muscular. 


Emaciation  slight. 
Blood  never  fibrinous. 
No  constant  lesions. 

Mortality,  16  to  SO  per  cent 


CEBEBRO-HPINAL     FKVKR 

iV  pandemic  disease. 
Non-contagious. 
Onset  sudden 
.More  in  young  persons. 
(Occurs  generally  in  winter. 
Duration,  indefinite;  usu- 
ally from  4  to  7  days 
Kemittent  defervescence. 

Relapses,  common. 
Countenance,  usually  pale 

or  cyanotic 
Pupils  unequal. 

Strabismus  common. 
Deafness  often  permanent, 

Skin  haft  no  peculiar  odor. 
Cutaneous  hypencsthesia. 

Eruptions  various;  mostly 
herpetic  and  petechial. 

Appeals  on  Is],  or  2d  day 

Ecchynioses,  common. 

Headache,  acute  and  ago 
nizing. 

Delirium  oAen  absent.  Be- 
gins on  first  or  second 
day. 

Temperature  fluctuating 
and  atypical 

Pulse  variable,  frequently 
slow. 

Bilious  vomiting  n  con- 
stant symptom. 

Tetanic  spasms  frequent. 

Pains  sharp,  lancinating 
and  neuralgic  in  charac 
ter,  in  spine  and  extrem- 
ities. 

Emaciation  marked. 

Blood  highly  fibrinous. 

Constant  lesions  of  the  cer- 
ebro-spinal  pia  mater. 

Mortality  20  to  75  per  cent. 


TYPHOID  FEVER. 

An  endemic  disease. 

Non-contagious. 

Onset  insidious. 

More  in  early  ^idult  life. 

Oecnrs  mostly  in  autumn. 

Duration  from  3  to  4  weeks. 

Defervescence  by  prolonged 
lysis. 

Relapses,  occasionally. 

Countenance,  pale  or  pur- 
plish-red. 

Pupils  equal,  often  dilated, 

Strabismus  absent. 
Deafness  occasionally  per- 
sistent. 
Skin  has  a  musty  odor. 


RoBe-iash,  seldom  absent. 

Appears  on  7th  to  0th  day. 
Kcchyiuoses,  rare. 
Headache,  dull. 

Cerebral     symptoms     ap- 
proach gradually. 

Temperature  range,  typi- 
cal. 
Pulse,  100  to  140. 

Vomiting,  occasional. 

Tetanic  spasms  rare. 
Pains,  dull  and  muscular. 


Emaciation  great. 
Blood  rarely  fibrinons. 
Constant  lesions  of  ileum 

and  mesenteric  glands. 
Mortality  15  to  20  per  cent 


1. 


■MMiMa 


mim 


FBOQNOHIS. 


237 


lOin  FEVER. 

nic  disease. 

ngious. 

lid  ions. 

early  ^idult  life. 

nostly  in  autumn. 

il'roiu3to4week8. 

cence  by  prolonged 

I,  occasionally, 
ance,  pale  or  pur- 
red, 
qual,  often  dilated. 

[iu8  absent. 

9  occasionally  per- 

t. 

IS  a  musty  odor. 


lA,  seldom  absent 

9  on  7th  to  9th  day. 
loses,  rare, 
he,  dull. 

d     symptoms     ap- 
h  gradually. 

fature  range,  typi- 

100  to  140. 

ng,  occasional. 

3  spasms  rare. 

dull  and  muscular. 


ition  great, 
rarely  fibrinous, 
nt  lesions  of  ileum 
mesenteric  glands. 
lity  16  to  5?0  per  cent 


Scarlet  fever  may,  in  the  early  hours  of  invaBion,  present  mnny 
of  the  initial  symptoms  of  cerebro-spinal  fever.  The  eorly  red- 
ness of  the  middle  of  Ihe  soft  palate,  and  the  rapid  oppearnnco 
of  the  scarlatinal  rash,  will  usually  enable  the  diognosis  to  be 
made  with  certainty. 

Pernicious  fever  may  be  confounded  with  the  fulminant  vari- 
ety, or  with  either  ot  the  other  varieties  B3  they  approach  con- 
valescence. The  main  points  of  diflference  may  be  summarized 
as  follows: — 


CEUKBRO-SPINAL    KEVEB. 

A  pandemic  disease. 

Chiefly  among  children. 

Occurs  mostly  iu  winter. 

Inceptive  chill  appears  suddenly;  usu 
ally  without  prodromes. 

Face  pale  or  cyuuntic. 

Eruption  on  llr.st  or  second  day. 

The  fever  rise  shows  marked  irregular- 
ity. 

Constipation  the  rule. 

Muscular  contractions  the  rule. 

Blood  highly  fibrinous;  absence  of  pig- 
ment. 

Spleen  slightly  enlarged. 


PERNlCIOVa  FEVEB. 

An  endemic  disease. 

Common  to  all  ages. 

Ocrcurs  mostly  in  spring  and  fall. 

Initial  chill,  usually  preceded  by  an 

intermittent  fever  paroxysm. 
Complexion  sallow. 
No  eruption. 
The  fever  rise  shows  marked  perio<lic- 

ity. 

At  times  diarrhoea. 

Muscular  contractions  rare. 

Blood  lacks  fibrin,   but  contains  free 


pigment. 
Spleen  enlarged  and  softened. 

Masked  small-pox,  which  at  times  resembles  this  disease,  may 
be  recognized  by  the  absence  of  tetanic  spasms  of  the  post-cer- 
vical muscles.  True  tetanus  is  distinguished  by  the  absence  of 
epidemic  influence,  by  the  history  of  the  case,  by  the  absence  of 
fever,  and  by  the  clearness  of  the  mental  faculties. 

Prognosis. — The  prognosis  con  never  be  made  with  certainty, 
as  the  course  of  the  disease  is  extremely  variable.  The  abortive 
and  fulminant  varieties  run  a  rapid  course,  and  terminate  in 
from  on^^  to  five  days.  The  simple  and  intermittent  varieties 
may  run  their  course  in  from  one  to  two  weeks  or  they  may  last 
for  months.  As  a  rule,  the  first  week  is  the  period  of  greatest 
danger.  The  usual  termination  in  fulminant  cases  is  death.  A 
steady  amelioration  of  all  symptoms  within  the  first  or  second 
week,  in  mild  or  moderately  severe  cases,  renders  a  favorable 
prognosis  possible.  Unfavorable  symptoms  are:  intense  excite- 
ment, early  appearance  of  symptoms  of  depression,  return  of 
the  vomiting,  intense  headache,  deer  and  persistent  coma,  ex- 


•  Mil  T  llitH 


1238 


LECTURES  ON   FEVEI18. 


lenBive  petechiro,  rwwwiing  convulsions,  nnd  irrogulnr  rospirn- 
tion.     UttlajweH  arc  not  infreijuent,  nnd  oft«u  provo  fatal. 

The  I  alio  of  mortality  varies  greatly  in  different  opidemios, 
but.  averages  about  forty  i>er  cent.  In  the  majority  of  cases, 
death  takes  place  by  failure  of  the  respiratory  nerve-ceuters. 


ogulnr  roHpirn- 
iv(»  fatal, 
cut  opidomioB, 
jority  of  caHOB, 
irve-oeuters. 


LECTURE  XVI. 

Cerebro-spiiial  Fever^  (  continued.  ) 

TREATMENT. 

Prophylaxis.— StatisticB  show  that  cerebro-spinal  fever  ap- 
pears most  frequently,  assumes,  as  a  rule,  its  worst  form,  and 
numbers  its  largest  percentage  of  victims  where  sanitary  re- 
quirements are  most  neglected.  Attention  should,  therefore, 
be  given  to  proper  sewerage  and  drainage,  and  to  the  prompt 
removal  of  all  refuse  and  decaying  matter  from  the  streets  and 
dwelling  places.  During  an  epidemic,  unusual  mental  and  bod- 
ily fatigue,  and  all  irregularities  in  the  mode  of  life,  should  be 
strictly  avoided.  Argenhtm  nit.  is  recommended  as  a  preventive 
for  the  simple  variety  and  nrseniate  of  quinine  for  the  intermit- 
tent form. 

Principal  Remedies.^The  remedies  that  oftenest  claim  atten-      • 
tion  at  the  outset  of  an  attack,  are  veratrum  vir.,  gelsemium, 
belladonna  and  solanum  nigrum. 

Veratrum  vir.  is  adapted  to  severe  cases,  and  more  especially 
■when  there  is  intense  brain  congestion  with  nausea  and  vomiting, 
a  hard,  full,  bounding  pulse,  and  marked  opisthotonos.  Qelsem- 
ium  is  indicated  in  mild  cases,  and  such  as  are  attended  by  a 
lesser  degree  of  inflammation  of  the  meninges.  The  pulse  is  usu- 
ally quick,  full  and  soft,  the  headache  is  heavy  in  character,  and  is 
located  mainly  in  the  occipital  region.  Belladonna  may  be  em- 
ployed when  there  is  more  or  less  active  delirium,  with  redness 
of  the  face  and  eyes,  and  alternately  contracted  or  dilated  pupils. 
Solanwn  nia.  takes  the  place  of  bell.,  when  spasms  and  convul- 

(239) 


I-*.-- 


240 


LECTURES  ON  FEVERS. 


siona  mark  tho  onset  of  the  disease.  Bhus  tox.  will  be  nee^d 
when  a  typhoid  state  supervenes,  and  especially  when  the  cuta- 
neous eruptions  are  of  a  multiform  character.  In  tl:  j  last  stages 
when  there  is  a  tendency  to  coma,  oinum  should  be  given. 

For  the  intermittent  variety  in  the  first  stages,  cedron,  arseniate 
of  quinine  and  the  picrate  of  ammonia  are  important  remedies. 
When  the  typhoid  state  is  engrafted  on  this  variety,  and  there  is 
great  restlessness  and  extreme  prostration,  arscnicum  alb.  will 
be  needed. 

In  fulminant  cases,  where  the  chill  is  prolonged  and  there 
seems  to  be  no  power  of  reaction,  camphor  should  be  given. 

Croiaius  may  at  times  render  valuable  semce  in  these  cases, 
particularly  when  the  petechial  phenomena  are  prominent.  Sc- 
calc  is  a  noteworthy  remedy  for  the  internal  congestion,  the  con- 
vulsive shocks  and  the  tetanic  phenomena. 

Verat  alb.  or  nux  vom.  mcy  be  needed  for  the  electric-shock- 
like pains  in  the  abdomen  and  extremities.  Cicuta  for  tonic 
spasms  of  all  the  muscles  of  the  body,  with  gastralgia  and  vio- 
lent vomiting.  Cimicifuga  when  spasms  and  obstinate  vomiting 
continue  after  the  acute  symptoms  subside.  Digitalis  when  the 
heart's  action  is  irregular  and  labored,  and  the  urine  is  dimin- 
ished in  quantity.  Physosiigma  when  there  is  contraction  of 
the  pupils,  with  a  tumultuous,  irregular  and  feeble  heart,  tetanic 
rigidity,  and  retraction  of  the  head. 

Bapiisia  may  be  administered  as  an  intercurrent  remedy  in 
the  typhoid  state,  when  general  paralysis  threatens,  the  excre- 
tions become  oflfensive,  and  the  blood  rapidly  tends  to  disorgan- 
ize .  Helleborus  is  called  for  when  there  are  indications  of  serous 
effusion,  and  when  the  phenomena  of  paralysis  have  become 
complete.  IgnaUa  and  cannabis  ind.  deserve  attention  when 
there  are  hysterical  symptoms  or  complications.  Phosphorus 
must  be  employed  when  pneumonic  complications  exist,  and.  when 
there  are  extensive  petechise. 

During  convalescence,  zincvm  or  anacardium  for  weakness  of 
memory;  plumbum  or  cuprum  for  paralysis;  and  silicea  or  sul- 
phur for  deafness,  may  be  needed. 

Leading  Indications. — Aconite.— During  or  after  the  chill. 
Dryness  of  the  skin,  with  restlessness  and  great  thirst.  A  quick, 
hard,  sharp  pulse  (bell).    Tearing  in  the  nape  of  the  neck;. 


LEADING   INDICATIONS. 


241 


?.  will  be  nee^d 
ly  when  the  cuta- 
In  tl;  J  last  stages 
d  be  given. 
I  cedron,  arseniaie 
jortant  remedies, 
riety,  and  there  is 
rscnicum  alb.  will 

longed  and  there 
should  be  given. 
ice  in  these  cases, 
)  prominent.  Se- 
Qgestion,  the  con- 
be  electric-shock- 
Cicuta  for  tonic 
istralgia  and  vio- 
bstinate  vomiting 
^igitah's  when  the 
le  urine  is  dimin- 
is  contraction  of 
jble  heart,  tetanic 

urrent  remedy  in 
eatens,  the  excre- 
:ends  to  disorgan- 
lications  of  serous 
'sis  have  become 
e  attention  when 
3ns.  Phosphorus 
ns  exist,  and  when 

rn  for  weakness  of 
ad  silicea  or  sul- 

)r  after  the  chill. 
b  thirst.  A  quick, 
lape  of  the  neck;. 


stiffness  of  the  back  [rhus).     Despairing  mood  and  fear  of 
death  (ors.).    In  plethoric  individuals. 

iEtliusa  cyu. — Vertigo  with  a  tendency  to  stupor  and  coma; 
obstinate  vomiting.  Tearing,  lancinating,  beating  pains  in  the 
occiput,  extending  all  over  the  head.  Face  pale  and  collapsed; 
eyes  staring;  pupils  dilated  and  insensible  to  light  {hyos. ).  Epi- 
leptiform convulsions.     During  dentition. 

AgaricilS  muse— "Vertigo;  great  weight  in  the  occiput;  the 
head  constantly  falls  backward.  Great  weight  in  the  forehead 
and  temples  with  delirium  and  coma.  Twitching  of  the  eye- 
lids and  eyeballs.  Twitchings  of  the  facial  muscles;  painful 
sensitiveness  of  the  scalp.  Stiffness  and  sensitiveness  of  the 
nape  of  the  neck  and  spine.  Violent,  burning,  shooting  pains 
deep  in  the  spine.     Paralysis  of  the  upper  and  lower  limbs. 

Ammonium  carb.— Oppressive  fullness  in  the  forehead  and 
vertex,  as  if  the  head  \iould  burst.  Kinging  in  the  ears;  swell- 
ing of  the  parotids  (mere).  Painful  stiffness  of  the  neck  and 
small  of  the  back.  Weak,  nervous  individuals  and  scrofulous 
children 

Anacardium.— Loss  of  memory;  weakness  of  all  the  senses 
{phos.  acid,  zincum).  Dull  pressure  as  with  a  plug  on  the  left 
side  of  the  vertex.  Cramps  in  the  calves  when  walking;  knees 
feel  paralyzed.     Hypochondriasis  {lye). 

Apis  mel.— Headache  with  vertigo;  brain  feels  tired;  burning 
and  throbbing  in  the  head,  relieved  by  pressure.  Sopor  inter- 
rupted by  piercing  shrieks  {hell,  hyos.).  Stiffness  in  the  back 
of  the  neck;  inability  to  hold  up  the  head.  (Edematous  swelling 
of  the  face  {ars.).  Sunken,  half-closed  eyes.  Stinging,  shoot- 
ing pains  all  over;  hyperaesthesia  of  the  sui-face;  soreness  of  the 
abdominal  walls.  Grating  of  the  teeth.  Scanty  urination  ( aco. ). 
Hurried,  difficult  respiration.  Variable  and  intermittent  pulse. 
Convulsions. 

Apocynum  cann.— Hydrocephalus;  open  sutures;  projecting 
forehead.  Constant,  involuntary  movement  of  one  arm  and  leg. 
Sight  of  one  eye  totally  lost.  Great  irritability  of  the  stomach 
with  distressing  vomiting.    Suppression  of  urine  {hyos.). 

Argentum  nit,— Violent  headache  with  vertigo.  Digging, 
cutting  pains  from   the  occiput  to  the  frontal  protuberance. 


■  {" 


242 


LECTURES  ON  FEVEB8. 


I 


:■  I- 


Painful  fullness  and  heaviness  in  the  head.  Intolerance  of 
light;  clouds  before  the  eyes;  double  vision  {hell).  Soporous 
sleep,  with  constant  murmuring.  Pale,  bluish,  sunXen  face. 
Tender,  easily  bleeding  gums  {nit  acid) .  Irresistible  desire  for 
sweets  {kali  curb.,  opp.  nit.  acid).  Violent  caidialgia  with 
griping  and  burning.  Stools  and  urine  pass  unconsciously.  Ir- 
regular, intermittent  pulse.  Tremulous  weakness.  Bluish-black 
eruption.    Epileptiform  convulsions. 

Arnica. — Stupid,  apathetic  state  {phos.  acid).  Pressive 
headache,  as  if  distended.  Sticking  pains  in  the  temple  and 
forehead.  Great  heat  in  the  head  with  coldness  of  the  body. 
Weakness  of  the  cenrical  muscles;  cervical  vertebrae  very  sensi- 
tive to  touch  and  pressure.  Soreness  in  all  the  limbs  {rhus)  as 
if  bruised.  Great  sinking  of  strength.  Ecchymosed  spots  on 
the  skin. 

Arsenicum  alb. — Great  restlessness,  fear  and  anguish  {aco- 
nite). Intense  headache  with  vertigo  and  humming  in  the  ears. 
Sensation  as  if  the  brain  beat  against  the  skull,  during  motion. 
Excessive  photophobia.  Stiflfness  of  the  nape  of  the  neck  and 
spine.  Death,iy  color  of  the  face.  Grinding  of  the  teeth  during 
sleep  {bell,  hell).  Dryness  of  the  mouth;  tongue  dry,  brown 
and  trembling  {loch.).  Difficult  breathing,  with  great  anguish; 
irregular,  quick,  weak  pulse.  Cramps  in  the  calves.  Epileptic 
convulsions.    Petechise.    Great  weakness  and  prostration. 

Baptisia. — Frontal  headache  with  pressure  at  the  root  of  the 
nose  {aconite).  Bruised  and  painful  feeling  at  the  base  of  the 
brain  and  upper  part  of  the  spinal  cord,  worse  on  stooping. 
Stiffiiess  and  lameness  of  the  cervical  muscles.  Bestless,  toss- 
ing about,  rolling  of  the  head  fron  one  side  to  another.  Constant 
biting  of  the  fingers,  and  moving  of  the  feet,  while  unconscious. 
Vertigo,  with  wandering  pains  in  the  limbs.  Stifiness  and  lame- 
ness all  over  the  body  {arnica).  Sensitiveness  of  the  stomach 
to  pressure  {hry. ) ;  sinking  gone  feeling  in  the  epigastrium  {hyd., 
ign.).    Urticarial  eruption  {apis). 

Belladonna. — Vertigo,  on  sitting  up  or  turning  over  in  bed, 
with  nausea  and  vomiting  {bry.,  puis.).  Alternate  paleness  and 
redness  of  the  face  {aco.).  Stupefaction  with  head  congestion, 
with  dilated  pupils  {hyos.);  double  vision,  rolling  and  squinting 
of  the  eyes.    Great  intolerance  of  light  (opp.  sirom.).    Violent 


LEADING  INDICATIONS. 


243 


.  Intolerance  of 
[hell).  Soporous 
ish,  BunXen  face, 
sistible  desire  for 
b  cardialgia  with 
aconsciously.  Ir- 
ass.    Bluish-black 

acid).  Pressive 
L  the  temple  and 
ness  of  the  body. 
rtebrsB  very  sensi- 
le  limbs  (rhus)  as 
bymosed  spots  on 

and  anguish  {aco- 
nming  in  the  ears. 
11,  during  motion. 
e  of  the  neck  and 
f  the  teeth  during 
ongue  dry,  brown 
ith  great  anguish; 
calves.  Epileptic 
prostration. 

at  the  root  of  the 
at  the  base  of  the 
'orse  on  stooping. 
IS.  Bestless,  toss- 
nother.  Constant 
rhile  unconscious, 
itiffuess  and  lame- 
)ss  of  the  stomach 
spigastrium  {hyd., 

■ning  over  in  bed, 
nate  paleness  and 
1  head  congestion, 
ling  and  squinting 
siroM.).    Violent 


throbbing  pain  extending  from  the  neck  into  the  head  {aamite, 
glon. ).  Jerking  headache,  with  inclination  to  bend  the  head 
backward.  Great  soreness  and  stifl&iess  of  the  neck.  Shooting 
and  gnawing  pains  in  the  spine  and  extremities.  Drowsiness, 
yet  inability  to  sleep  ( lack ).  Restless  sleep  with  frequent  start- 
ings  (hyos.,  opium).  Spasmodic  distortions  of  the  face  and  lips. 
Delirium,  with  grinding  of  the  teeth  and  inclination  to  bite. 
Nausea  with  cutting,  gnawing  pain  in  the  stomach.  General 
hypersBsthesia  (coffea).  Eetention  of  urine  or  involuntary  mic- 
turition. Coldness  of  the  extremities  with  heat  of  the  head. 
During  dentition;  and  in  young,  full-blooded  individuals. 

Bryonia.—Extremely  irritable  ( cham. ).  Vertigo  on  sitting  up 
in  bed  {aco.,  puis.).  Splitting  headache,  worse  from  motion, 
and  on  opening  the  eyes,  especially  in  the  morning.  Tearing 
pain  in  the  right  side  of  the  head  {bell,  opp.  aco.).  Dark  red 
face,  suddenly  changing  color.  Chewing  motions  during  sleep. 
Child  cries  when  taken  up  or  moved.  Drowsy  sleep  (rhus). 
VivJu,  'rightful  dreams.  Pressive  pain  in  the  occiput,  drawing 
dow  .   he  neck,  with  stiffness.    Pain  in  the  back  and  limbs, 

as  ii  ."  .d  {aim.).  Loss  of  appetite;  soreness  of  the  stomach 
(bell).  Tongue  thickly  coated  white  or  else  dry  and  brownish. 
Hasty,  impetuous  drinking  and  swallowing;  desire  for  large 
quantities  of  water.  Dysuria;  constipation.  Dry,  burning  heat 
all  over,  especially  in  the  head. 

Camphor. — Great  anxiety  and  extreme  restlessness  {ars.). 
Vertigo  with  heaviness  of  the  head,  and  constriction  at  the  base 
of  the  brain.  Throbbing  in  the  cerebellum.  Deadly  paleness 
of  the  face.  Severe  chill  with  coldness  of  the  face,  tongue,  lipg 
and  extremities.  Icy  coldness  of  the  whole  body.  Sudden  and 
great  sinking  of  strength  ( ars. ).  Violent  cramps  in  the  stomach 
and  limbs.  Suffocative  dyspnoea.  Small,  weak,  slow  pulse.  Ri- 
gidity  of  the  limbs,  clinching  of  the  teeth,  and  retraction  of  the 
head.    Tetanic  spasms;  epileptiform  convulsions. 

Cannabis  ind.— Vertigo  on  rising,  with  stunning  pain  in  the 
occiput  Violent  shocks  through  the  brain.  Involuntary  move- 
ments  of  the  head.  DUatation  of  the  pupils  with  sensitiveness 
to  light  ( bell ).  Extreme  sensitiveness  to  noise.  Paleness  of  the 
face.    Suffocative  dyspnoea.    Irregular,  feeble  pulse.    Hysteria 


r^^Ms^t&smsiem 


iriWigf >Wiii':' " 


^1 


2M 


LECTURES  ON  FEVERS. 


Hal- 


oal  symptoms;  emprosthotonos  with  loss  of  consciousness, 
lucinations. 

Cantharis. — Anxious  restlessness ;  great  mental  activity.  Am- 
orous frenzy.  Dysuria,  or  retention  and  suppression  of  urine. 
Violent  burning  and  lacerating  pain  in  the  occiput  Stiffness  of 
the  neck,  with  tearing,  lancinating  pains  extending  up  into  the 
head.  Oppression  of  the  chest.  Tearing  in  the  limbs,  relieved 
by  rubbing.  Over-sensitiveness  of  the  whole  body.  Albumin 
nous  urine. 

Cicuta  vir.— Vertigo,  with  jerking  and  twitching  of  the  head. 
Severe  occipital  headache.  Tonic  spasms  of  the  cervical  mus- 
cles ;  retraction  of  the  head.  Pupils  dilated  and  insensible  ( h(dl. ) ;. 
double  vision  (/tyos.).  Deafness.  Grinding  of  the  teeth  (etna. » 
ign. ).  Jerking  of  the  eyeballs  and  facial  muscles;  spasmodic 
distortion  of  the  limbs;  opisthotonos.  Tonic  spasms  renewed 
from  the  slightest  touch  or  noise.  Convulsions  with  screaming. 
Violent  hiccough.  Clenching  of  the  teeth;  inability  to  swallow. 
Dyspnoea.  Gastralgia  with  vomiting  and  painful  distension  of 
the  abdomen.    Great  agitation. 

Oimicifnga. — Intense  pain  in  the  head;  brain  feels  too  large 
{nux)  Pain  at  the  base  of  the  brain  and  along  the  spine.  Sen- 
sitiveness of  the  spine.  Stiffness  and  retraction  of  the  musclea 
of  the  neck  and  back.  Intense  aching  pain  in  the  eyeballs  ( bry. ). 
Redness  of  the  fauces  and  palate.  Circumscribed  or  diffused 
muscular  soreness  (am.).  Great  sensitiveness  of  the  skin. 
Profuse,  general  perspiration;  creeping  chills  down  the  back. 
Alternate  tonic  and  clonic  spasms.  Obstinate  sleeplessnesa 
(coff..  opium).  Delirium  resembling  delirium  tremens  (digit)',. 
Bees  cats  and  dogs,  fear  of  death  {aconite). 

Cocculus. — Vertigo  with  inclination  to  vomit  on  rising  {bry.). 
Headache  as  if  the  eyes  would  be  torn  out.  Violent  pains  in 
the  forehead;  convulsive  trembling  of  the  head.  Pale,  sallow, 
bloated  face.  Hardness  of  hearing;  noise  in  the  ears  like  the 
rushing  of  waters  {theridion).  Swelling  and  induration  of  the 
sub-maxillary  glands  (mere).  Violent  cramp  of  the  stomach 
{coloo.).  Spasmodic  oppression  of  the  chest;  heavy,  laborious 
respiration.  Weakness  of  cervical  muscles,  with  inability  ta 
support  the  head.  Painful  stiffness  of  the  neck.  Vivid,  fearful 
dreams;  fainting  fits,  hysterical  and  epileptiform  convulsions^ 


LEADING   INDICATIONS. 


245 


siousnesB.    Hal- 

il  activity.  Am- 
ression  of  urine, 
mt  Stiffness  of 
Jing  up  into  the 

limbs,  relieved 
[body.    Albumin 

• 

ing  of  the  head. 

le  cervical  mus- 

i8ensible(6<'//.);. 

the  teeth  {cma.^ 
icles;  spasmodic 
jpasms  renewed 
with  screaming, 
►ility  to  swallow. 
:ul  distension  of 

1  feels  too  large 
the  spine.  Sen- 
1  of  the  musclea 
>  eyeballs  (6ry.). 
ibed  or  diffused 
ss  of  the  skin, 
down  the  back. 
lie  sleeplessness 
remens  (digit.) -^ 

m  nsmg  (bry.). 
Violent  pains  in 
Pale,  sallow, 
e  ears  like  the- 
duration  of  the 
)f  the  stomach 
leavy,  laborious 
ith  inability  to 
Vivid,  fearful 
m  convulsions. 


Miliary  cutaneous  eruptions.    Trembling  of  all  the  limbs  (ijjn.). 
Paralysis. 

Crotalns. — Intense  headache;  pain  as  from  a  blow  on  the  oc- 
ciput. Delirium  with  open  eyes.  Extreme  pallor  of  the  face; 
anxiety  and  dyspnoea.  Pain  in  the  epigastrium;  unq  lenchable 
thirst;  faintuess  and  vomiting.  Pain  in  the  extremities.  Ecchy- 
moses;  convulsions;  paralysis. 

(yliprnni. — Anguish  with  great  restlessness  and  tossing  about 
(ars.).  Afraid  of  falling;  clings  tightly  to  the  nurse.  Bruised 
feeling  deep  in  the  brain,  and  in  the  orbits  on  turning  the  eyes 
{[fels.,  hell).  Convulsive,  motions  of  the  eyes  (gels.).  Stupor, 
with  twitching  and  jerking  of  the  limbs.  Coldness  of  the  hands; 
bluish  appearance  of  the  fingers.  Deep,  sunken  eyes,  with  blue 
rings  around  them.  Spasmodic  distortions  of  the  face;  the 
tongue  is  alternately  protruded  and  withdrawn,  with  great  rapid- 
ity. Violent  intermittent  contractive  pains  in  the  stomach;  ten- 
derness of  the  abdomen.  Painful  contraction  of  the  chest, 
esj)ecially  after  drinking;  dyspnoea.  Clonic  spasms;  epilepti- 
form convulsions.  Herpetic  eruption.  In  children  during  den- 
tition. 

Digitalis. — Great  pressure  and  weight  in  the  head;  severe 
lancinating  pains  in  the  vertex  and  occiput.  Stupor  with  dila- 
tation of  the  pupils.  Stiffness  of  the  cervical  muscles.  Tearing, 
cutting  pains  in  the  nape  of  the  neck.  Inability  to  support  the 
head  from  weakness  of  the  cervical  muscles.  Sleep  with  sudden, 
cracking  noises  in  the  head,  frequent  startings  and  dreams  of 
falling.  Deathly  nrusen;  convulsive  efforts  at  vomiting  {tart, 
emet.).  Vomiting  with  coldness;  prostration;  faintness*.  sensi- 
tiveness in  the  epigastrium.  Extremely  slow  pulse  {cann.  ind), 
si  times  intermittent  and  irregular.  Feeble,  irregular,  and  la- 
bored action  of  the  heart  Irregular,  difficult  and  sighing  res- 
piration. 

Oelseminni.— Brain  feels  as  if  bruised  {ctipt.,  hell).  Dull- 
ness of  the  mental  faculties  {bapt);  feels  as  if  intoxicated. 
Great  exhaustion  and  drowsiness.  Heat  of  the  head  with  icy 
cold  hands  and  feet.  Feeling  as  ot  a  band  around  the  head, 
above  the  ears  {mere).  Convulsive  movements  during  sleep. 
Itching  of  the  head,  face  and  neck.  Paralysis  of  the  eyelids. 
Double  vision;  dilated  pupils.  Naiisea  and  vomiting,  with  weak. 


-_j 


'.rsvAanirrr. 


246 


LECTURES  ON  FEVERS. 


scarcely  perceptible  pulse.  Feeble,  labored  respiration.  Trem- 
bling and  complete  loss  of  muscular  jwwer.  Inability  to  direct 
the  movements  of  the  limbs.  Neuralgic  and  rheumatic  pains  in 
the  extremities  {bry.,  dm.,  rhus).  Yellowish-white  coating  on 
the  tongue;  dysphagia.  Sweating  relieves  (opp.  mere).  In 
children  and  nervous  people. 

Olonolne.— Congestion  of  the  head  with  a  sense  of  expansion. 
Fullness  and  pulsation  in  the  head  (6eW.).  Undulating,  wave- 
like motion  in  the  brain  ( hyos. ).  Pain  along  the  whole  length  of 
the  spine.  Pains  ascend  from  the  chest  and  neck  to  the  occiput. 
Optical  illusions;  eyes  injected  and  rolled  upwards;  pupils  di- 
lated {bell).  Blindness  with  faintness  and  nausea.  Bluish 
pallor  under  the  eyes.  Deafness  with  ringing  in  the  ears.  Al- 
ternating redness  and  palen^^ss  of  the  face.  Nausea  and  vomit- 
ing with  headache.  Pulse  mostly  accelerated;  often  rises  and 
falls,  alternately.    Sudden  spasms. 

HellelJOrus.— Vertigo.  Stupefaction  with  sensation  of  sore- 
ness in  the  back  part  of  the  head,  as  if  bruised.  Boring  of 
head  in  pillow  (apis).  Face,  pale  and  cedematous.  Frequent 
rubbing  of  the  nose  (dna).  Constant  chewing  motions  (bry.); 
grating  of  the  teeth  ( hyos. ).  Drinks  cold  water  hurriedly;  rolls 
the  tongue  from  side  to  side.  Automatic  motion  of  the  arm  and 
leg  on  one  side.  Convulsive  movements  of  the  muscles  (c«p)-.). 
Soporous  sleep  with  screaming  and  starting.  Nausea  with  vom- 
iting of  green  mucus  {ipecac).  Urine  scanty  and  dark,  with  a 
sediment  like  coffee-grounds.  Bapid,  small,  tremulous  pulse. 
Hydrocephalus.    In  scrofulous  children;  during  dentition. 

Hyoscyamns. — Pressive,  stupefying  headache.  Undulating 
sensation  in  the  brain  {ghn. ).  Violent  pains  in  the  head  alter- 
nating  with  pains  in  the  nape  of  the  neck.  Pressuru  in  the 
vertex  and  drawing  in  the  nape  of  the  neck,  when  turning  the 
head.  Sensation  as  if  the  brain  were  shaken  and  loose  (bell), 
Startings  from  fright  {geh.);  grinding  of  teeth  {hell).  Dim- 
ness of  vision,  paralysis  of  the  tongue;  constriction  of  the 
throat.  Inability  to  swallow  fluids  (6eZZ.,  s/rcn.).  Involuntarj' 
stools  and  urine,  or  else  retention.  Stiffiiess  of  the  cervical 
muscles.  Convulsive  jerks  of  muscles  {bell).  Stiffness  of  the 
arms  and  legs ;  jerking  of  the  hands  and  feet.  Bigidity.  Spasms 
of  the  chest,  with  arrest  of  breathing.    Small,  quick,  intermit* 


I 


.[.(■.HHHliil  I  j.J«wiitivUl.....lii."' 


jpiration.  Trem- 
Inability  to  direct 
leumatio  paius  in 
T^Iiite  coating  on 
fpp.  mere),     in 

ise  of  expansion. 
'nduJnting,  wave- 
e  whole  length  of 
ck  to  the  occiput, 
^ards;  pupils  di- 
nausea.    Bluish 
in  the  ears.    Al- 
iusea  and  vomit- 
often  rises  and 

snsation  of  sore- 
sed.    Boring  of 
tous.    Frequent 
motions  (bry.); 
I  hurriedly;  rolls 
ti  of  the  arm  and 
muscles  (cupr,). 
ausea  with  vom- 
^nd  dark,  with  a 
remulous  pulse. 
',  dentition. 

e-    Undulating 
the  head  alter, 
'ressuro  in  the 
en  turning  the 
d  loose  (bell.)^ 
(hell).    Dim- 
riction  of  the 
Involuntarj' 
f  the  cervical 
itiffness  of  the 
dity.    Spasms 
lick,  intermit^ 


LEADING   INDICATIONS. 


241 


tent  pulse.    Cutaneous  hypersesthesin.    Epileptiform  convulsions. 

Ignatia. — Changeable  disposition;  alternate  gaiety  unci  tours 
{hifos.).  Pressing  headache,  as  from  a  nail,  from  witliin  to  with- 
out. Jerking  headache,  aggravated  by  raising  the  eyes.  Con- 
vulsive movements  of  the  eyes  and  lids.  Twitching  of  the 
muscles  of  the  face.  Spasmodic  constriction  of  the  chest;  fre- 
quent sighing.  Throbbing  in  the  abdomen  (afcw^s).  Stiffness  of 
the  nape  of  the  neck  {kali  cnrb.,  lack.).  Convulsive  jerking  of 
the  arms  and  legs  {siram, ).  Over-sensitiveness  tt)  pain  (coffcd); 
hysteria.  Violent  pain  in  small  spots,  only  discovered  on  toucii- 
ing  them.  Convulsions.  During  dentition;  or  after  fright  or 
grief. 

Lacliesis. — Pressive  headache,  over  the  eyes  and  in  the  occi- 
put. Pains  extend  from  the  head  to  the  neck  and  shoulders; 
heaviness  in  the  occiput  with  vertigo.  Stiffness  of  tlie  nape  of 
the  neck  (rhus).  Pricking,  pulsating,  tearing  pains.  Cramp- 
like  pain  in  the  precordial  region,  with  irregular  action  of  the 
heart.  Oppression  of  the  chest.  Difficult  speech;  tongue  trem- 
bles when  protruded,  or  catches  behind  the  teeth.  Solids  swal- 
low better  than  liquids.  Cannot  bear  the  clothing  tight  around 
the  waist  (opp.  nit.  acid).     Miliary  eruption. 

Laurocerasus. — Stupefying  pain  in  the  head;  brain  feels  as 
if  loose.  Twitching  and  convulsions  of  the  facial  muscles 
{cictda).  Difficult  deglutition  (stram.).  Lock-jaw  (hyos.). 
Spasmodic  oppression  of  the  chest.  Irregular  beating  of  the 
heart,  with  slow  pulse  (dig.).  Stiffness  in  the  nape  of  the  neck 
and  small  of  the  back.  Stinging,  tearing  in  the  extremities. 
Rapid  sinking  of  the  vital  forces  {camphor,  verat). 

Lycopodium. — Dread  of  being  alone.  Stupefying  headache, 
extending  down  the  neck,  worse  from  4  to  8  p.  M.  Pressive 
headache  in  the  vertex  {niujc).  Stiffness  of  the  neck;  tensive 
pain  in  the  neck  and  occiput.  Drowsiness,  with  loud  screams 
during  sleep;  ill-humor  after  sleep.  Over-sensitiveness  of  hear- 
ing with  roaring  in  the  ears  {cann.  ind.).  Over-sensitive  smell; 
fpn-like  motion  of  the  nostrils.  Pendulum-like  motion  of  ihe 
tongue,  which  is  swollen.  Sinking  of  the  lower  jaw  {opium,  mux, 
mur.  add).  Yellowish-gray  color  of  the  face  {ars.);  blue  rings 
around  the  eyes.  Tension  in  the  abdomen  and  chest  as  from  a 
hoop  {cact).    Burning  pains  between  the  shoulders  {phos.). 


848 


LECTU11E8    ON    FEVERS. 


Drawing,  tearing  iu  the  limbs  at  night  (mere).  Numbness  and 
twitching  through  tlxe  body  and  limbs.  Pneumonic  complica- 
tions (p/ios.), 

Nux  yoni.— Drawing,  tearing,  jerking  pains  in  tho  head,  from 
the  orbit  to  the  occiput.  Shocks,  starting  suddenly  from  one 
portion  of  the  brain,  with  numbness  and  drawing  in  the  limbs. 
Sensation  as  from  a  bruise  in  the  back  of  the  head.  Over-sen- 
sitiveness to  external  impressions.  Heaviness  and  stiflfness  in 
the  neck.  Tearing  pain  in  the  nape  of  tho  neck  and  back  (puis.). 
Stitches  through  the  body  in  jerks.  Paleness  of  the  face; 
twitching  of  the  facial  muscles.  Straining  to  vomit,  first  water, 
then  food  (opp.  ipecac).  Opisthotonos  with  unconsciousness. 
Convulsions  renewed  by  the  slightest  touch  (strain.). 

Opium.— Stupefaction  with  half-open  eyes;  deep,  slow,  snor- 
ing respiration.  Stupid  sleeplessness  with  frightful  dreams. 
The  occiput  feels  as  heavy  as  lead;  the  head  falls  back,  con- 
stantly. Thf;  eyes  are  fixed  and  half-closed  (bell);  pupils  con- 
tracted (hijos.,  physosiigma)  or  dilated,  insensible  to  light. 
Dark-red,  bloated  face;  relaxation  of  the  muscles,  with  twitch- 
ing of  the  lips  and  flapping  of  the  cheeks.  Lock-jaw.  Opistho- 
tonos (nux).  Abtlomen  hard,  distended,  and  sensitive  to  the 
touch.  Pulse  variable;  very  quick  or  very  slow.  Dyspnoea. 
Spasmodic  jerkings,  and  numbness  of  the  limbs.  Heat  with 
sweat;  sleep  with  sweat;  worse  while  perspiring  (mere,  opp. 
gels.);  bed  feels  so  hot,  cannot  lie  on  it.  Convulsions,  with  loud 
screams  on  entering  the  fit. 

Oxalic  acid.— Pressing  in  small  spots  in  the  head.  Pale, 
sunken  face.  Dryness  in  the  throat  with  difficult  deglutition. 
Stomach  very  sensitive  to  pressure.  Oppression  of  the  chest. 
Pain  in  the  back,  between  the  shoulders,  extending  to  the  loins. 
Coldness  and  numbness  of  the  hands;  stiffness  and  paralysis  of 
the  lower  extremities.  Pains  appear  periodically.  Thinking  of 
the  symptoms  aggravates  them  (opp.  camphor). 

Pliospliorus.— Stupefying  headache,  with  acuteness  of  smell 
(hell,  lye).  Burning  and  stinging  pains  and  pulsations  com- 
mencing in  the  occiput.  Stiffness  in  the  nape  of  the  neck,  sen- 
sitiveness of  the  spine;  back  pains  as  if  broken.  Difficulty  of 
hearing,  especially  of  the  human  voice;  contracted  pupils  (opi- 


I 


LEADING  INDICATIONS. 


249 


Numbness  and 
|inonic  complica- 

tho  liead,  from 

Itlenly  from  one 

piig  in  the  limbs. 

lend.     Over-seu- 

and  stiffness  in 

ind  back  (puis.). 

ss  of  the  face; 

3mit,  first  water, 

mconsciousness. 
am. ), 

leep,  slow,  snor- 
ightful  dreams, 
falls  back,  cou- 
^i- ) ;  pupils  con- 
iisible  to  light, 
les,  with  twitch- 
:-jaw.     Opistho- 
sensitive  to  the 
ow.     Dyspnoea, 
lbs.    Heat  with 
ig  (mere,  opp. 
sions,  with  loud 

le  head.  Pale, 
ult  deglutition. 
1  of  the  chest, 
ng  to  the  loins, 
nd  paralysis  of 
.    Thinking  of 

»ness  of  smell 
lulsations  com- 
the  neck,  sen- 
Difficulty  of 
'd  pupils  (opi- 


nm,  physos.).  Face  bloated  or  cadaverous-looking.  Formication 
and  tearing  in  the  limbs.  Soreness  of  the  abdomen  and  stomach 
to  touch.  Spasmodic  contractions  of  the  chest  (moschus). 
Dyspnoea  with  inability  for  exertion.  Pneumonic  complications 
(lye).  Extensive  petechiee  or  hemorrhages.  After  over-doses  of 
camphor. 

PhyHOStigma. — Contraction  of  the  pupils  (opp.  l)ell.).  Obsti- 
nate constipation,  with  flatulent  distension  of  abdomen.  Pain 
in  the  stomach  immediately  after  eating.  Tetanic  spasms  with 
irregular,  tumultuous  i/ction  of  the  heart.  Epileptiform  con- 
vulsions. 

Plunibllin. — Heaviness  in  the  head,  especially  in  the  cerebel- 
lum. Sudden  deafness.  Twitching  and  jerking  in  the  limbs. 
Sharp,  neuralgic  pains  in  the  lower  limbs  occurring  in  parox- 
ysms; hyperaBsthesia.  Paralytic  weakness  in  the  limbs;  wasting 
of  the  muscles  of  paralyzed  parts. 

Rhu8  tox. — Stupefaction ;  vertigo  when  rising  from  the  bed 
(bry.,  gels. ).  Anxiety  with  great  restlessness  (ars. ).  Disturbed 
sleep  with  vivid,  frightful  dreams.  Fullness  and  bruised  pain 
in  the  head  extending  to  the  ears;  aching  in  the  occiput.  Hem- 
orrhage from  the  ears  and  nose.  Swelling  and  hardness  of  the 
salivary  glands.  Dryness  of  the  mouth  with  much  thirst  (nit 
acid).  Thirst  for  cold  water  or  cold  milk.  Red,  dry  and  cracked 
tongue  (hapt,  bell).  Various  eruptions;  red  rash  all  over  the 
body;  eczema  on  the  face  (lye,  mere).  Short,  dry  cough  from 
tickling  in  the  bronchi  (riimex).  Sensation  of  weakness  and 
trembling  in  the  heart  (bell,  spig. ).  Pains  in  the  shoulders  and 
back  as  if  strained.  Tearing  tensive  pains,  with  stiffness  of 
muscles  and  joints. 

Solannm. — Terrific  headache,  as  if  the  head  would  split  Rav- 
ing delirium;  convulsions  with  moaning  and  coma.  Violent 
subsuitus  tendinum;  tetanic  rigidity  of  the  whole  body.  Con- 
traction of  the  pupils;  slowness  of  the  pulse.  Neck  feels  stiff 
and  sore,  as  if  bruised  (am.).  Weakness  and  bruised  feeling 
in  the  back  and  limbs  (rhus,  rhod.).  Stiffness  and  convulsions 
excited  by  tht:  least  touch. 

Spongia. — Heat  in  the  head  with  redness  of  the  face  (bell). 
Pressing,  knocking,  pulsating  pain  in  the  forehead.     Dull  head- 


S60 


LECTUUE8  ON   FEVEB8. 


ache  in  the  right  side  of  the  brain,  better  when  lying  in  the 
horizontal  position.  Stupid  slumber;  frequent  waking  with  a 
start.  Painful  stiftheBs  of  the  muscles  of  the  neck  and  throat 
Throwing  the  head  backwards  with  tension  in  the  neck.  Double 
vision;  staring  eyes.  Dyspnoea  and  great  wet\kness  in  the  chest 
Full,  hard,  frequent  pulse. 

Stranionium. — Convulsive  movements  of  the  bead,  mostly  to 
the  right  side;  head  bent  forward  instead  of  back.  Head  and 
face  hot;  limbs  cold.  Furious  delirium  (6eZ/.).  Indiflference  to 
persons  or  things  {phos.  acid)',  calls  for  persons  who  are  present, 
but  does  not  know  them.  Stammering  or  speechlessness. 
Screaming  as  if  frightened  on  waking  (hell).  Conjunctivie  in- 
jected; pupils  dilated  {hell,  hifos.)',  transient  total  blindness. 
Bright  light  and  glistening  objects  cause  convulsions.  Great 
dryness  of  the  mouth  and  fauces.  Dysphagia  {bell,  hyoa.). 
Trembling  and  convulsive  movements  of  the  limbs.  Suppres- 
sion of  all  secretions  and  excretions.  Intense  scarlet  rash  over 
the  whole  body  {bell,  rhus).    Suppressed  miliary  eruptions. 

8iilphnr. — Heaviness,  fullness  and  pressure  in  the  forehead. 
Pain  as  if  the  brain  were  beating  against  the  skull  {nux,  spig.). 
Scalp  painfully  sensitive  to  the  touch  {cinch.).  Sweat  on  the 
head  of  a  musk-like  odor.  Pale,  distorted  features.  Ulceration 
of  the  margins  of  the  lids  {mere).  Pustules  and  ulcers  on 
and  around  the  cornea  {lack.,  sil).  Sour  smell  from  the 
mouth,  especially  in  the  morning.  Hardness  of  hearing  {caust); 
ringing  and  roaring  in  the  ears  {dnch.).  Drawing,  tension  and 
stitches  in  the  nape  of  the  neck.  Drawing,  tearing  pains  in 
the  limbs.  Cramps  in  the  calves  of  the  legs  and  soles  of  the 
feet  especially  at  night  {ailicea).  Turbid  urine  (iac/t.)  with 
red  sediment 

Tarantula.— Intense  headache,  deep  in  the  brain,  aggravated 
by  touch,  with  restlessness  and  anguish.  Sensation  as  of  cold 
water  being  poured  (dropped,  cann.  sat.)  on  the  head.  Pain  in 
the  occiput  as  if  striking  it  with  a  hammer.  Pricking  itching 
sensations  over  the  whole  body.  Convulsive  trembling  of  the 
body. 

Teratrnm  alb. — Violent  headache  with  delirium;  or  uncon- 
sciousness. Boiling  of  the  head  from  side  to  side,  with  short 
screams;  boring  the  head  in  the  pillow  (opts).     Convulsive 


LEADINQ   INDICATIONS. 


251 


en  lying  in  the 
waking  with  a 
leek  and  throat. 
|e  neck.  Double 
|ies8  in  the  chest 

head,  mostly  to 
ick.     Head  and 
Indifference  to 
who  are  present, 
speechleBsness. 
ConjunctivBB  in- 
total  blindness, 
mlsions.    Great 
a  (bell,  hyos.). 
mbs.    Suppres- 
icarlet  rash  over 
ry  eruptions. 

in  the  forehead. 
uU  {nux,  spig.). 
'  Sweat  on  the 
res.  Ulceration 
I  and  ulcers  on 
smell  from  the 
learing  {must); 
ing,  tension  and 
earing  pains  in 
ind  soles  of  the 
ne  (lack.)  with 

■ain,  aggravated 
ation  as  of  cold 
head.  Pain  in 
ricking  itching 
embling  of  the 

ium;  or  uncon- 
ide,  with  short 
I.     Convulsive 


ehocks  and  vomiting  as  soon  as  head  in  raised.  SpnHruH  with 
convulsive  motions  of  the  limbs.  StiffnoHs  of  the  neck.  Pali>> 
cold,  sunken,  pointed  face  {(irn.,  camphor).  Cold  sweat  on  the 
forehead.  Violent  vomiting,  with  nausea  and  great  exhaustion. 
Tongue  cold  {carbo  m/. );  or  red  and  swollen  (^'//.,  rhun). 
Cramps  in  the  calves  («»//>/(. ).  Tingling  and  coldness  of  the 
limbs.  Icy  coldness  of  the  hands  and  feet  Feeble,  irregular, 
intermittent  pulse.    Sudden  sinking  of  strength  {ara.,  camphor). 

Veratriim  vir. — Severe  frontal  headache  with  vomiting.  Ver- 
tigo and  headache  with  dilated  pupils  and  dimness  of  vision. 
Headache  proceeding  from  the  nape  of  the  neck  («am/.).  Trem- 
bling as  if  frightened  and  on  the  verge  of  spasms.  Boiling  of 
the  head  and  eyes.  Opisthotonos.  Sudden  spasms  with  niiusea, 
vomiting  and  utter  prostration.  Constant,  severe,  aching  pain 
in  the  neck  and  shoulders.  Convulsive  twitchings  of  the  mus- 
cles of  the  face  {cicuta,  gels.).  Frtce  flushed  {bell.);  or  pale, 
and  covered  with  a  cold  perspiration  {lu^at  alb.).  Coldness  of 
the  whole  body  {verai.  alb.).  Dryness  of  the  mouth  and  lips. 
Bed  streaks  in  the  middle  of  the  tongue;  yellow  edges.  Small- 
est quantity  of  food  causes  vomiting.  Spasms  of  the  oesophagus; 
painful,  almost  constant  hiccough.  Oppression  of  the  chest 
Galvanic-like  shocks  in  the  extremities.  Paralysis.  In  plethoric 
individuals. 

Zincum. — Betarded  convalescence,  with  weakness  of  memory 
{anac.,  nux).  Frequent  attacks  of  vertigo.  Pressure  in  small 
spots  on  the  head.  Stiffness  and  pain  in  the  cervical  and  upper 
dorsal  muscles.  Bruised  pain  in  the  small  of  the  back.  Alter- 
nate paleness  and  redness  of  the  face  (aconHc).  Earache.  Dry- 
ness and  constriction  in  the  throat  with  accumulation  of  mucus. 
Gagging  and  vomiting  with  ravenous  hunger  and  obstinate  con- 
stipation. Scanty,  turbid  urine  as  if  mixed  with  clay.  Dysuria. 
Involuntary  urination  while  coughing  or  sneezing  (catist). 
Twitching  and  jerking  through  the  whole  body  during  sleep. 
Drawing,  tearing  pains  in  the  limbs.  Stiffness  of  the  joints  with 
transverse  lancinating  pains  above  the  joints.  Cannot  keep  the 
feet  still.    Exhaustion  of  nerve  force.    Profuse  sweats. 

HYGIENIC  AND  DIETETIC  TREATMENT. 

The  general  management  of  cerebro-spinal  fever  may  be 
summed  up  in  a  few  words.    The  sick  room  should  be  darkened 


ICBMe 


1169 


L»f;TniEH  ON   FKVEHH. 


and  well  ventilftted,  nnd  the  stricteHt  (luiotiule  olmerved.  A  hot 
liiUHtiinl  foot  bath  «)r  ft  genernl  hot-hnth  ( 1(K).5 '  Fnhr.  to  102" 
Ffthr.)  Hhould  l)e  employed  hh  enrly  nH  piw/iihle.  Hot  water 
may  be  applied  by  a  Hiwiiige  paHHod  over  the  Hpine  every  two 
or  three  hours.  Or  a  coniproBH  wrung  out  of  hot  water  may  b«> 
kept  conBtantly  applied  to  the  nape  of  the  neck.  Continuous 
heat  is  employed  in  preference  to  cold,  aw  the  tendency  to  early 
dopression  is  frequently  counteracted  by  it.  Stimulation  with 
brandy  or  whisky  must  be  resorted  to  whenever  symptoms  of 
depression  of  the  nervous  system  show  themselves.  The  amount 
of  stimulation  necessary  will  be  regulated  as  in  other  fevers  by 
the  pulse,  and  tirst  sound  of  the  heart. 

The  diet  sliould  consist  of  milk,  meat-juice,  broths,  light  soups, 
and  light  farinaceous  foods.  It  should  be  given  at  intervals  of 
two  hours  during  the  day,  and  three  hours  during  the  night,  ex- 
cept when  resting  quietly.  Solid  food  may  be  allowed  as  soon 
as  the  patient  is  able  to  digest  it. 

When  spasms  or  irritability  of  the  etomach  render  the  admin- 
istration of  footl  and  medicines  by  the  mouth  impossible,  nutri- 
tious enemas  should  be  employed,  and  the  medicine  administercMl 
hypodermatically  (page  98.). 

In  cases  attended  with  great  prostration,  as  there  is  danger  of 
syncope,  the  patient  should  be  kept  constantly  in  the  recumbent 
posture.  , 


l)Herve(l.  A  hot 
'  Fnhr.  to  102" 
>lfl.  Hot  water 
spine  every  two 
i)t  wftter  inny  b«> 
ck.  Continuous 
andenoy  to  early 
Simulation  with 
Br  symptomg  of 
38.  The  amount 
other  fevers  by 

)th8,  light  Boups, 
)n  at  intervals  of 
ag  the  night,  ex- 
I  allowed  as  boou 

jiider  the  admin- 
np^SBible,  nutri- 
ine  administenul 

lere  is  danger  of 
n  the  recumbent 


LECTURE  XVII. 

Influenza. 

l)eftnltlon.-Influenza  is  a  miaBmaticcontagi^ous  ^li«««««.  "^ 
from  three  to  ten  days'  duration,  duo  to  >^-^-^:^^^^\.^'^^^ 
Bgent,  and  occurring  only  in  wide-spread  epidemics,  l^^^^' 
acterized  by  suddenness  of  onset;  by  great  and  early  prostration, 
:"-  development  of  general  catarrhal  ^y^P^--  J-; 
ally  there  is  intense  frcmtal   headache    coryza    sofe  tlm,at,  a 

Lkling  cough,  dyspncea.  !>«--»«- ^^^.""^^  ^^tltt^^^^^^^ 
varying  intensity,  and  great  nervous  depression.  At  times  there 
Is  more  or  less  severe  catarrh  of  the  gastro-entenc  mucous  mem- 
brL  with  hepatic  disturbance.  Inflammatory  affections  of  the 
lungs  Ire  not  rare  complications.  The  disease  is  very  rarely 
fH  ex  e^t  in  advanced  life.  When  death  takes  place,  it  i» 
generally  the  result  of  complications.  Relapses  are  not  uncom- 
mon. 

Syiionyiii8.-Epidemic  catarrhal  fever.     Epidemic  catarrh. 

La  Grippe. 

History.-  Although  influenza  is  a  disease  which  is  supposed 
to  have  prevailed  from  remote  antiquity,  it  has  been  c  early  re- 
corded  only  since  the  beginning  of  the  fourteenth  century.  In 
1311  and  1403  a  very  fatal  epidemic  prevailed  m  Branca  In 
1510  an  epidemic,  starting  in  Malta,  spread  in  a  northwester  y 
direction,  and  traversed  the  whole  of  Europe.  A  rapidly  spread- 
ing  epid;mic  started  in  Asia  in  1557,  and  extending  to  Europe 
Tnd  America,  encircled  the  globe.  In  1^80  ^great  epidem^^^ 
taking  a  northwesterly  course,  overran  Asia,  Africa  and  Europe. 
During  the  seventeenth  century  several  epidemics  are  recorded 


1 


254 


LECf  URE8  ON  FEVERS. 


as  having  occurred  throughout  Europe,  Great  Britain  and  Amer- 
ica. A  wide-spread  epidemic  swept  over  Europe  in  1729  and 
1730.  Two  years  later  a  mild  and  slowly-spreadiing  epidemic 
started  in  Saxony,  traveled  in  a  northwesterly  direction  until  it 
reached  the  British  Isles,  and  there  dividing  and  passing  in 
southward,  westward  and  southeasterly  directions,  it  traversed 
the  American  continent,  the  West  Indies  and  eastern  Europe. 
Several  widely-extended  epidemics  prevailed  in  Europe,  Amer- 
ica and  the  West  Indies  between  the  years  1737  and  1780.  A 
remarkable  epidemic  startinj  in  Asia  in  1782  traveled  westward 
through  Europe,  and  even  attacked  the  crews  of  ships  upon  the 
high  seas.  Children  were  relatively  exempt  from  seizure  during 
this  epidemic.  Numerous  recurring  outbreaks  occurred  in  Eu- 
rope and  America  from  1788  to  1827.  In  1830  tha  disease  began 
in  China,  and  by  a  series  of  wide  and  rapidly  spreading  epidem- 
ics, in  a  tour  which  occupied  two  years,  again  encircled  the 
world.  In  1837  it  reappeared  in  Bussia,  and  again  spread  over 
Europe.  From  this  time  on  till  1850-51  numerous  epidemics 
occurred.  In  the  United  States  the  epidemic  of  1843  was  re- 
markable for  the  greatness  of  its  extent  Since  1850  all  epidem- 
ics of  influenza  have  run  a  comparatively  mild  course.  Extensive 
but  mild  epidemics  prevailed  as  epizootics  among  domestic  ani- 
mals throughout  the  United  States  and  Canada,  in  1872,  1880 
and  1882. 

Etiology. — The  causes  of  influenza  are  of  two  kinds,  predis- 
posing and  exciting. 

1.  The  Predisposing  Causes. — Climate  has  no  direct  influence 
upon  the  extent  of  the  prevalence  of  the  disease.  Its  course  is 
not  cyclical  nor  is  it  in  any  way  connected  with  known  atmos- 
pheric conditions.  It  appears  in  every  latitude,  and  prevails 
alike  in  hot  and  dry,  or  cold  and  wet  seasons. 

Age  exerts  little  influence  as  a  predisposing  cause.  Infirm 
and  aged  persons  are  supposed  to  be  most  susceptible.  In  some 
epidemics  children  are  almost  exempt. 

Sex  in  itself  !ias  no  influence  upon  the  course  of  the  disease, 
although  statistics  show  that  in  most  epidemics  females  are  the 
first  to  be  attacked. 

Occupation  does  not  in  any  way  predispose  to  influenza. 
The  mode  of  life  of  the  individual  exerts  little  influence. 


Britain  and  Amer- 
iurope  in  1729  and 
spreading  epidemic 
ly  direction  until  it 
ing  and  passing  in 
actions,  it  traversed 
nd  eastern  Europe. 
'  in  Europe,  Amer- 
1737  and  1780.    A 
2  traveled  wes^vard 
8  of  ships  upon  the 
from  seizure  during 
aks  occurred  in  Eu- 
JOtha  disease  began 
'  spreading  epidem- 
gain  encircled  the 
again  spread  over 
umerous  epidemics 
mic  of  1843  was  re- 
ice  1850  all  epidem- 
l  course.    Extensive 
mong  domestic  ani- 
lada,  in  1872,  1880 

two  kinds,  predis- 

no  direct  influence 
Base.  Its  course  is 
'ith  known  atmos- 
tude,  and  prevails 

ing  cause.     Infirm 
ceptible.    In  some 

•se  of  the  disease, 
ics  females  are  the 

to  influenza. 

5  little  influence. 


% 


CLINICAL  HISTORY. 


255 


Overcrowded  or  illy  ventilated  habitations  are  supposed  to  f  nvor 
the  greater  prevalence  of  the  disease. 

Previous  attacks  aflbrd  no  protection. 

Epidemics  do  not  follow  the  great  lines  of  human  travel,  but 
extend  over  vast  areas,  usually  in  a  direction  from  the  east  or 
northeast  toward  the  west  and  south.  At  times  they  radiate  in 
different  directions  from  various  centers.  The  rate  of  progress 
of  the  epidemic  influence  may  be  either  slow  or  rapid.  "When 
it  enters  a  locality,  it  prevails,  as  a  rule,  from  one  to  two  months. 

2.  The  Exciting  Cause. — The  nature  and  origin  of  the  mor- 
bific agent  of  influenza  remains  as  yet  unknown.  It  is  generally 
supposed  to  be  a  living  miasm  having  an  independent  existence, 
and  capable,  to  a  slight  extent,  of  l)eing  reproduced  in  or  about 
the  human  body,  and  of  being  transmitted  by  the  air,  or  by  the 
persons  or  clothing  of  those  affected.  The  period  of  incubation 
varies  from  a  few  hours  to  several  days. 

Clinical  History.— The  course  of  an  attack  of  influenza,  which 
may  be  either  mild  or  severe,  will  depend  partly  upon  the  char- 
acter of  the  epidemic,  partly  upon  the  activity  and  quantity  of 
the  morbific  agent,  and  partly  upon  the  power  of  resistance  of 
the  patient  In  mild  cases  there  is  a  general  feeling  of  malaise, 
followed  by  a  sub-febrile  state  attended  with  ner/ous  prostration 
and  slight  catarrhal  symptoms. 

In  severe  cases  the  onset  of  the  attack  is  usually  abrupt.  A 
chill  or  chilliness  alternating  with  heat  marks  the  invasion  of 
the  disease.  The  fever,  which  soon  follows,  may  be  either  mod- 
erate or  of  high  grade,  and  displays  a  tendency  to  morning  re- 
missions. Intense  frontal  headache,  with  pains  in  the  orbits,  in 
the  region  of  the  antrum  of  Highmore,  and  the  Eustachian  tube, 
and  at  the  root  of  the  nose,  appears  early.  Sneezing,  swelling 
and  redness  of  the  eyelids  and  nostrils,  a  watery  discharge  from 
the  nose,  lachrymation  and  loss  of  the  sense  of  smell,  rapidly 
supervene.  The  throat  becomes  sore,  and  then  is  loss  of  taste 
and  appetite.  A  dry,  tickling  paroxysmal  cough  appears,  at- 
tended by  more  or  less  hoarseness,  chest  pain,  and  dyspnoea. 
The  pulse  is  full  and  but  slightly  increased  in  frequency.  There 
is  restlessness,  pain  in  the  extremities  and  great  nervous  depres- 
sion. Cutaneous  hypersesthesia  occasionally  occurs.  At  times 
symptoms  of  catarrhal  disturbance  of  the  gastro-intestinal  tract 


k 

m 


1 


256 


LECTURES  ON   FEVERS. 


predominate.  Exceptionally  the  disease  attacks  tlie  mucou» 
surfaces  of  the  head,  chest  and  abdomen. 

The  continuance  of  the  fever  is  usunlly  of  short  duration.  At 
the  end  of  four  or  five  days  defervescence  sets  in,  and  the  tem- 
perature returns,  at  times  gradually,  oft«ner  rapidly,  to  the 
standard  of  health.  When  complications  appear  the  fever  may 
continue  ten  or  twelve  days.  The  defervescence  is  often  marked 
by  copious  perspiration,  an  increased  flow  of  urine  depositing 
urates,  or  a  spontaneous  flux  from  the  bowels.  The  catarrhal 
symptoms  usually  disappear  within  two  or  three  days  after  def- 
ervescence, while  the  cough  and  expectoration  may  continue  for 
an  indefinite  period. 

Inflammatory  lung  complications,  such  as  capillary  bronchitis 
or  catarrhal  pneumonia,  occur  in  from  five  to  ten  per  cent  of  the 
cases.  They  occur  of tener  in  old  persons,  and  in  those  of  feeble, 
delicate  constitutions.  Recrudescences  of  fading  neuralgias  are 
not  uncommon. 

Duration. — The  mildest  form  of  influenza  lasts  two  or  three 
days.  The  severe  type  runs  its  course  in  from  four  to  ten  days. 
When  complications  exist,  weeks  may  elapse  before  recovery 
takes  place. 

ANALYSIS    OF    CHART. 

The  Temperature. — The  fever  is  extremely  variable.  It 
ranges  from  100°  or  102°  Fahr.  in  moderate  cases,  to  104°  Fahr. 
in  the  more  severe  forms.  It  is,  as  a  rule,  higher  at  night  than 
in  the  daytime.  In  the  aged  and  infirm  it  is  apt  to  run  an  ady- 
namic course. 

The  Pulse. — ^The  pulse  is  as  changeable  as  the  temperature. 
It  is  moderately  increased  in  frequency. 

The  Nervous  System. — In  most  epidemics  great  and  early 
prostration  is  a  marked  symptom.  Headache  appears  early,  and 
is  persistent  It  is  commonly  frontal,  sometimes  general,  and  is 
severe  in  character.  It  usually  increases  in  severity  towards 
evening.  Deep-seated  pains,  due  to  the  general  hypersemia  and 
catarrhal  inflammation  of  the  mucous  lining  of  the  cavities  of 
the  head,  are  referred  to  the  frontal  sinuses,  antrum  of  High- 
more,  Eustachian  tube  and  middle  ear.  Soreness  and  a  bruised 
feeling  in  the  limbs,  and  dull,  tearing  pains  in  the  joints  are 
almost  constant  symptoms;  while  stitches  in  the  chest  are  not 


the  mucous 

duration.  At 
,  and  the  tem- 
ipidly,  to  the 
the  fever  may 
often  marked 
ne  depositing 
The  catarrhal 
lays  after  def- 
,y  continue  for 

lary  bronchitis 
per  cent  of  the 
those  of  feeble, 
neuralgias  are 

its  two  or  three 
»ur  to  ten  days, 
lefore  recovery 


y  variable.  It 
3,  to  104°  Fahr. 
r  at  night  than 
;  to  run  an  ady- 

le  temperature. 

great  and  early 
)pear8  early,  and 
s  general,  and  is 
severity  towards 
.  hypersemia  and 
f  the  cavities  of 
mtrum  of  High- 
BE  and  a  bruised 
in  the  joints  are 
he  chest  are  not 


ANALYSIS  OF  CHART. 

CHART  XI.— Influenza. 


257 


Nature: 

Epideralo.                         Mla8ii>;.t>-conta(fiou8. 

Duration: 

Two  to  ten  Du;'*. 

Initial  Symptom: 

A  cbtll,  or  (!blllinc88  altcrnatinir  with  beat. 

Temperature: 

102"  to  KM"  Fabr.       Hemittent  and  variable. 

Pulse: 

Variable.       Moderately  aeceleraled. 

Nose: 

Sneezing.       Abundant  discbarge.       Kedness.       Eplstaxls. 

Byes: 

Lacbrymatlon.       Eyelids  swollen  and  reddened. 

Chest: 

Paroxysmal  racking  cough.       Myalgia.       DyBpna>a. 

Nervous  System: 

Frontal  headache.    Sleeplessness.     Mild  delirium.     Sever*  pains  in 
the  back  and  limbs. 

Throat: 

Sore  throat.       Pharyngitis.       Tonsilitls.       Hoarseness. 

Dlsrestive  Tract: 

Anorexia.    Loss  of  taste.    Coated  tongue.    Constipation  or  diarrhea 

Urine: 

Diminished.       Deposits  urates. 

CutaneousSurface 

Hot  and  dry.       Hyperwsthesia.       Sudamina.       Herpes  labialls. 

Complications: 

Capillary  bronchitis.   Catarrhal  pneumonia.  Parotitis. 

Prognosis: 

Favorable,  except  in  very  young  or  very  old  persons. 

Relapses: 

Not  uncommon. 

Recurrence: 

A  previous  attack  affoi-ds  no  protection. 

Incubation : 

From  a  few  hours  to  two  or  three  weeks. 

uncommon.  In  severe  cages  the  patients  are  generally  restless 
and  anxious,  and  there  is  marked  insomnia.  Mild  delirium  fre- 
quently occur8,but  is  mostly  transitory.  In  the  worst  types  there 
may  be  cramps,  tremors  and  subsultus  tendinum.  Old  neural- 
gias sometimes  reappear  during  convalescence. 

The  Respiratory  Tract.— The  mucous   membrane  of  the 
respiratoiy  tract  is  more  or  less  hyperaemic;  the  discharge  from 


riMHMM 


M 


wm 


258 


LECTUUES  ON  FEVEBS. 


the  nostrils  is  abundant;  the  lachrymation  and  the  sneezing  are 
strongly  marked.  The  sore  throat  is  attended  by  more  or  less 
difficulty  in  swallowing  and  hoarseness.  Troublesome  laryngitis 
and  chronic  bronchitis  sometimes  remain  as  sequels.  Cough, 
which  is  almost  always  a  prominent  symptom,  is  frequent  and 
distressing  in  character.  Occasionally  it  becomes  spasmodic, 
simulating  whooping  cough.  It  is  generally  worse  towards  night. 
It  is  apt  to  be  dry  at  the  outset,  but  is  attended  by  more  or  less 
muco-serous  or  muco-purulent  expectoration  as  the  disease  pro- 
gresses. Dyspnoea  is  a  not  unfrequent  symptom,  and  may  be 
either  of  nervous  origin  from  disturbance  of  the  vagus,  or  due 
to  existing  complications. 

Capillary  bronchitis  and  catarrhal  pneumonia  are  not  uncom- 
mon complications.  The  latter  often  appears  insidiously  about 
the  fourth  or  fifth  day.  Lobar  pneumonia,  as  manifested  by 
dullness,  crepitus,  bronchial  respiration  and  i-usty  sputa,  some- 
times occurs  as  a  late  complication.  Pleurisy,  except  as  associ- 
ated with  lobar  pneumonia,  is  rarely  met  with;  at  times  it  is 
associated  with  pericarditis.  Localized  collapse  of  the  lung 
often  occurs. 

The  Digestive  Tract.— The  thirst,  loss  of  appetite,  and  im- 
paired taste  are  due  to  the  catarrhal  state.  Nausea  and  vomiting 
sometimes  occur.  Swelling  of  the  parotid  glands  is  occasionally 
present.  The  tongue  is  usually  pasty,  and  coated  with  a  whitish 
or  yellowish-white  fur.  Tenderness  in  the  epigastrium  and  con- 
stipation are  present  in  a  large  proportion  of  cases.  In  some 
forms  an  intestinal  catarrh  gives  rise  to  more  or  less  diarrhea 
and  colic  pain. 

Tlie  Urine. — The  urine  presents  the  characteristics  of  febrile 
urine  in  general.  Its  amount  varies  with  the  quantity  of  fluids 
ingested.  As  a  rule,  it  is  diminished;  at  times  it  becomes  sup- 
pressed. It  is  frequently  cloudy,  and  contains  an  abundance  of 
urdtes  towards  the  close  of  the  disease. 

Tlie  Cntaneous  Snrface.— At  the  outset  of  the  attack,  the 
skin  is  hot  and  dry;  later  on,  sweating  frequently  occurs.  Co- 
pious acid  sweats  are  not  uncommon  during  defervescence. 
Plentiful  crops  of  sudamina  frequently  appear  as  a  result  of  the 
abundant  perspiration.    An  outbreak  of  herpes  occasionally  oc- 


MMMMMMMM 


the  sneezing  are 

by  more  or  less 

esome  laryngitis 

sequels.    Cough, 

is  frequent  and 

iomes  spasmodic, 

rse  towards  night. 

)d  by  more  or  less 

,s  the  disease  pro- 

)tom,  and  may  be 

the  vagus,  or  due 

lia  are  not  uncom- 

insidiously  about 

as  manifested  by 

rusty  sputa,  some- 

\f,  except  as  associ- 

(dth;  at  times  it  is 

llapse  of  the  lung 

)f  appetite,  and  im- 
fausea  and  vomiting 
ands  is  occasionally 
>ated  with  a  whitish 
pigastrium  and  con- 
of  cases.  In  some 
ore  or  less  diarrhea 

acteristics  of  febrile 
le  quantity  of  fluids 
mes  it  becomes  sup- 
,inB  an  abundance  of 

et  of  the  attack,  the 
3[uently  occurs.  Co- 
iring  defervescence, 
ear  as  a  result  of  the 
rpes  occasionally  oc- 


DIFFEBENTIAL  DIAGNOSIS. 

curs,  and  is  a  favorable  indication.    The  general  sensibility  of 
the  surface  is  not  infrequently  increased. 

Horbid  Anatomy. — The  anatomical  lesions  of  influenza  are 
mainly  restricted  to  the  upper  air-passages  and  bronchial  tubes, 
and  consist  of  congestion  and  catarrhal  swelling  of  the  mucous 
lining.  The  bronchial  glands  occasionally  become  enlarged. 
When  complications  exist,  changes  of  lung  tissue  marked  by 
hyperaomia,  oedema,  hypostatic  congestion,  splenization  or  hepat- 
ization, are  observed. 

DifTerential  Diagnosis. — Although  there  are  no  special  diag* 
nostic  signs  that  can  be  regarded  as  characteristic  of  influenza, 
its  discrimination  is,  under  ordinary  circumstances,  unattended 
with  difficulty.  The  march  of  the  epidemic,  the  large  number 
of  persons  attacked,  the  prominence  of  nervous  symptoms,  the 
early  prostration,  and  the  annoying  cough  disproportionately 
severe  in  comparison  with  the  physical  signs,  are  distinguish- 
ing  symptoms. 

It  may  be  confounded  with  simple  catarrh,  acute  bronchitis, 
and  typhoid  fever. 

Simple  catarrhs  are  due  to  sudden  changes  in  the  weather, 
and  usually  appear  as  spring  approaches,  while  influenza  epi- 
demics occur  without  regard  to  the  seasons. 

Acide  bronchitis  is  a  bilateral  bronchial  affection,  characterized 
by  a  harsh  cough  with  frothy,  sometimes  bloody,  expectoration. 
Its  physical  signs  are  dry,  sonorous  or  sibilant  rales,  succeeded 
after  twenty-four  or  forty-eight  hours  by  large  and  small,  moist, 
mucous  rales.  When  there  is  considerable  secretion,bronchial 
fremitus  is  marked. 

Typhoid  fever  differs  from  influenza,  in  having  a  typical  tem- 
perature curve,  a  rapid  pulse,  a  rose  eruption,  and  pea-soup  dis- 
charges. 

Prognosis. — The  prognosis  varies  in  different  epidemics,  bat 
is  generally  favorable  except  at  the  extremes  of  life.  Yarions 
affections  of  the  respiratory  organs  often  appear  as  sequels. 
When  death  results  it  is  mostly  from  complications. 

Treatment. — Prophylaxis. — During  the  visitation  of  an  in- 
fluenza epidemic,  the  weak  and  the  aged,  and  such  as  are  en- 
feebled by  chronic  maladies,  should  be  well  taken  care  of.  All 
susceptible  individuals  should  remain  indoors  after  sunset  The 


? 


.1 

j  i  i 


260 


LECTDBES   ON  FEVERS. 


iodide  of  arsenicum  3rd  trit.,  arum  drac.  1st  trit,  or  sticta  1st 
dil.,  may  be  administered  morning  and  evening  as  a  preventive. 

Principal  Remedies. — Camphor  may  be  of  service  during  the 
first  few  hours  of  an  epidemic.     Oclsemium  will  be  needed  wlien 
the  febrile  symptoms  are  of  a  remittent  character,  chills  run 
along  the  back,  the  face  is  flushed,  the  eyes  are  suffused,  and 
there  is  a  thin,  watery,  non-irritating  discharge  from  the  nostrils. 
Arsenicum  iodide,  when  there  are  alternate  chills  and  heat, 
and  when  the  discharges  from  the  nostrils  are  watery,  irritating 
and  corrosive  in  character.    Arsenicum  alb.,  when  the  disease  is 
located  principally  in  the  nose  and  larynx.    The  discharge  from 
the  nostrils  is  copious,  watery  and  excoriating.     There  is  obsti- 
nate ophthalmia,  headache,  burning  in  the  frontal  sinuses,  larynx 
and  trachea,  and  great  prostration.    Merciirius  viviis  at  the  out- 
set, frequent  sneezing  with  profuse  coryza,  short,  dry,  racking 
night  cough,  with  painfulness  of  the  whole   thorax,  and  after- 
wards frothy,  mucous  expectoration.     It  is  also  of  service  when 
there  is  severe  gastric  catarrh  and  diarrhea.    Bryonia  in  old 
people  and  when  the  affection  is  seated  mostly  in  the  large  bron- 
chi.   There  is  distressing  frontal  headache,  dry  nasal  catarrh, 
continuous,  irritating,  violent  cough,  worse  in  the  daytime,  fre- 
quently causing  retching,  pains  in  the  chest,  soreness  and  shoot- 
ing, tearing  pains  on  motion  all  over  the  body.    Potassium  iodide 
for  painful  violent  sneezing  with  profuse,  acrid,  watery  discharge, 
and  lachrymation;  and  when  there  is  a  troublesome  irritating 
cough,  with  oppression  of  breathing,  and  gray,  sweetish-salt 
expectoration.    Sticta  for  violent  sneezing,  with  intense  head- 
ache and  conjunctivitis.    And  when  the  attacks  are  preceded  by 
rheumatic  pains  and  swelling  of  the  small  joints.     Eryngium 
aqnaticum  for  raw,  smarting,  burning  sensations  in  the  throat 
and  larynx  with  constant  irritating  cough,  and  tenacious,  yellow 
mucous  expectoration.    Euphorhium  for  frontal  headache,  watery 
discharge  from  eyes  and  nose,  with  burning  and  smarting  pains 
in  the  back  and  limbs.    Eupaiorium  perf.  when  the  bone  pains 
are  excessive  and  there  is  intense  bronchial  irritation  with  severe 
cough.    i2/(MS  iox.,  at  the  beginning  when  there  is  lameness  or 
soreness  in  the  extremities  as  if  bruised;  or  a  short,  dry,  night 
cough  aggravated  by  motion  or  currents  of  cold  air.     Wyethia 
when  there  is  dryness  in  the  pharynx,  with  burning  and  dryness 
in  the  epiglottis,  and  a  dry,  hacking  cough.  Senecio  for  catarrhal 


t^ttm>tmmmmmmtaimmmmtmtm> 


rtf  tjnet,  .-aicg-.^g-'ai- 


LEADING  INDICATIC  IS. 


261 


trit.,  or  sticta  1st 
g  as  a  preventive. 

ervice  during  the 
1  be  needed  when 
•acter,  chills  run 
fire  suffused,  and 

from  the  nostrils. 

chills  and  heat, 

watery,  irritating 
hen  the  disease  is 
he  discharge  from 
y.    There  is  obsti- 
ital  sinuses,  larynx 
IS  vivus  at  the  out- 
jhort,  dry,  racking 
thorax,  and  after- 
80  of  service  when 
a.    Bryonia  in  old 
r  in  the  large  bron- 

dry  nasal  catarrh, 
a  the  daytime,  fre- 
soreness  and  shoot- 
Poiassium  iodide 
\,  watery  discharge, 
iblesome  irritating 
gray,  sweetish-salt 
with  intense  head- 
sks  are  preceded  by 

joints.  Eryngium 
nations  in  the  throat 
id  tenacious,  yellow 
fcal  headache,  watery 
and  smarting  pains 
vhen  the  bone  pains 
xritation  with  severe 
here  is  lameness  or 
ir  a  short,  dry,  night 

cold  air.  Wyethia 
burning  and  dryness 
Senecio  for  catarrhal 


affections  of  the  stomach  and  bowels,  mucous  coughs,  or  ob- 
structed menstruation.  Cnrdmis  when  hepatic  symptoms  are 
marked.  Arum  drac.  when  laryngeal  symptoms  predominate. 
Vcrat  alb.  when  prostration  is  extreme.  Sabadilla  for  excessive 
sneezing.  Euphrasia  or  allium  ccpa  for  excessive  lachrymation. 
Hyoscyamus  for  spasmodic  cough,  worse  on  lying  down.  Co- 
nium,  after  gelsemium,  if  the  cough  is  relieved  by  the  expecto- 
ration of  a  mass  of  frothy  mucus  with  yellow  nucleus.  Tartar 
emel.,  kali  bich.  and  niiraie  of  sanguinaria  for  the  bronchitis. 
Phosphorus  when  the  disease  is  localized  in  the  larynx  or  there 
is  a  tendency  to  pneumonia.  Sulphur,  phos.  or  ailphium  for 
non-tubercular  pulmonary  affections  occurring  as  sequels. 

Leading  Indications. — The  guiding  symptoms  for  the  differ- 
ent remedies  may  be  compiled  as  follows: 

Aconite.— Chilliness  with  burning  heat  in  the  head  and  face. 
High  febrile  excitement  with  full,  hard,  quick  pulse.  Anxiety 
and  great  restlessness.  Distressing  pressure  at  the  root  of  the 
nose  {mere).  Short,  dry,  racking  cough  from  tickling  in  the 
larynx,  with  or  without  oppression.  Stitches  in  the  chest  {bry. ). 
Internal  shuddering  with  dry,  hot  skin  and  tendency  to  uncover. 
Sudden  suppression  of  perspiration.  Coryza  with  sneezing 
(sang.).    After  exposure  to  cold  west  winds  (hepar). 

Allium  cepa. — Violent  sneezing  with  profuse  acrid  coryza 
{mere. ).  Smarting  of  the  eyes  with  profuse  bland  lachrymation 
ieuph.).  Headache  with  coryza,  upon  entering  a  warm  room 
{pids.).    Hacking  cough  from  inhaling  cold  air  {ars.). 

Ammonium  carb.— Fluent  coryza,  with  stoppage  of  the  nose. 
Burning  water  runs  from  the  nose  {mere.  eor. ).  Roughness  and 
scraping  in  the  throat  {caust).  Cough  worse  after  midnight. 
In  delicate  women. 

Ammonium  mur. — Frequent  sneezing.  Watery,  acrid  dis- 
charge from  the  nose,  corroding  the  lips  {mere.  cor.).  Loss  of 
smell.    Loss  of  appetite.    Hoarseness  and  burning  in  the  larynx. 

Arsenicum  alb. — Frequent  sneezing,  with  profuse  watery  dis- 
charge from  the  nose,  corroding  the  lips  and  making  the  upper 
lip  sore  {arum.,  mere.  cor. ).  Profuse  lachrymation  and  burning 
in  the  eyes  {aconite).  Inflammation  of  the  eyes;  photophobia. 
Extreme  debility  with  dyspnoea  on  lying  down.    Great  thirst 


] 


262 


LECTUnES  ON  FEVEBS. 


with  chilliness  after  drinking.  Desire  for  ncids,  cold  water  or 
spirits.  Spnsmodic  cough  with  desire  tt)  vomit;  worse  after 
midnight,  nft«?r  eating  and  on  lying  down.  Cough  with  frothy, 
tough  expectoration.  When  coughing  a  pain  extend&  from  the 
lumbar  region  dowil  into  the  thighs.  Diarrhea;  the  evacuations 
excoriate  the  anus  {mere).  Great  restlessness  and  anxiety, 
especially  at  night. 

Arsenicum  iodide. — Chilliness  alternating  with  flashes  of 
heat.  Sneezing  with  irritating,  corrosive  discharge.  Short,  dry 
cough  Avith  tightness  in  the  chest;  worse  in  the  open  air  (opp. 
puis.).    Fuffiness  of  the  lower  lids  and  face  {apis,  euphorb.). 

Arum  drac. — Dryness  and  stiffness  of  the  eyelids  with  smart- 
ing and  burning.  Shooting  pains  in  the  ears,  with  accumulation 
of  mucus  in  the  Euftachian  tube.  Dryness  and  smarting  in  the 
throat,  with  hawking  and  constant  coughing  {sang.  nit).  Bat- 
tling of  mucus  in  the  larynx  at  every  expiration,  with  cough. 
Paroxysms  of  dyspnoea  at  night,  with  aching  in  the  chest.  Great 
muscular  weakness  and  prostration. 

Badiaga. — Spasmodic  cough,  with  sneezing  and  lachrymation. 
Fainfulness  of  the  left  eyeball.    Pressing  of  the  hands  upon  the 
head  while  coughing.     The  cough  is  loose  in  the  forenoon  but- 
tight  towards  evening  and  at  night.     Scrofulous  inflammation  of 
the  eyes,  with  induration  of  the  Meibomian  glands. 

Belladonna. — Dryness  of  the  nose,  with  dull  frontal  headache. 
Frequent  sneezing;  sore  throat  and  hoarseness.  Throbbing 
headache,  worse  from  motion  and  coughing.  Great  dryness 
of  the  mouth  and  throat.  Swelling  and  tension  of  the  upper 
lip  {calc.).  Hot  skin,  with  inclination  to  perspire.  Drowsiness 
Avith  starting  during  sleep  {ars.,  mere).  Barking  cough  {dros., 
verb(tscum).  Dry,  spasmodic,  or  hollow  hoarse  cough,  worse  at 
night  {dros.). 

Bryonia. — Headache  in  tae  morning,  when  first  opening  the 
eyes.  Dry  coryza  with  inflamed  and  ulcerated  nostrils.  Great 
irritability.  Pain  in  all  the  limbs,  aggravated  by  motion.  Dry 
cough  with  pain  and  soreness  in  the  pit  of  the  stomach.  Urina- 
tion when  coughing  {etna).  Tight  cough,  worse  through  the 
day,  from  entering  a  warm  room  and  from  motion.  Desire  to 
lie  down  and  remain  quiet. 


■HiHIili 


^C!r 


M) 


LEADING   INDICATIONS. 


263 


ids,  cold  water  or 
omit;  worse  after 
ougU  with  frotliy, 
exteiuk  from  tlie 
a;  the  evacuations 
aess  and   anxiety, 

g  with  flashes  of 
sharge.  Short,  dry 
he  open  air  (opp. 
{apis,  euphorh.). 

eyelids  with  sraart- 
1,  with  accumulation 
and  smarting  in  the 
;  {sang.  nit).  Rat- 
iration,  with  cough, 
in  the  chest.  Great 

ig  and  lachrymation. 
:  the  hands  upon  the 
in  the  forenoon  but 
lous  inflammation  of 
glands. 

lull  frontal  headache, 
rseness.  Throbbing 
ling.  Great  dryness 
tension  of  the  upper 
)erspire.  Drowsiness 
Barking  cough  {dros., 
oarse  cough,  worse  at 

hen  first  opening  the 
irated  nostrils.  Great 
rated  by  motion.  Dry 
:  the  stomach.  XJrina- 
;h,  worse  through  the 
)m  motion.    Desire  to 


Calcarea  carb. — Frequent  sneezing  with  coryza.  Painless, 
morning  hoarseness  {canst).  Chest  painful  to  the  touch,  and 
on  inspiration.  Loose  cough  with  rattling  of  mucus  in  the  chest. 
Night  cougb.  Profuse  head  sweat  when  sleeping.  Weight  in 
the  stomach  soon  after  eating.  In  scrofulv»U8  persons  and  U^eth- 
ing  children. 

€arbo  veg. — Fluent  coryza,  with  evening  hoarseness.  Burn- 
ing  in  the  eyes  and  profuse  lachrymation  (mere).  Beatiiif*  or 
pulsating  headache  {bell).  Painful  stitches  through  tlui  heiid 
when  coughing  {hry.).  Cough,  at  long  intervals,  aggravated  by 
breathing  cold  air.  Soreness  of  the  chest,  and  heat  of  the  body 
when  coughing.     Profuse  and  constant  flow  of  stringy  saliva. 

Causticuni. — Paroxysmal  cough  with  pain  in  the  hips  and  in- 
voluntary urination  {bry.,  cina).  Morning  hoarseness;  loud 
rales  when  coughing.  Violent,  hollow,  dry  cough,  worse  at  night 
on  getting  into  bed;  better  in  bed,  and  from  drinking  cold  water. 
Pain  in  the  malar  bones;  stiffness  and  lameness  in  the  jaws. 
Backache,  especially  in  the  coccyx.  Much  thirst  for  cold  drinks. 
Aversion  to  sweet  things;  fresh  meat  causes  nausea  and  water- 
brash. 

Chamomilla. — Fluent,  acrid  discharge  from  the  nose.  Hoarse- 
ness and  cough,  from  rattling  of  mucus  in  the  bronchi.  Suffo- 
cative constriction  in  the  upper  part  of  the  chest  with  constant 
desire  to  cough.  Stitches  in  the  chest  {bry.).  Inability  to 
swallow  solid  food  (opp.  ignatia).  Children  want  to  be  carried 
and  are  very  irritable. 

Cimicifuga.— Heat  in  the  head  "with  fluent,  watery  coryza. 
Stoppage  of  the  nose,  with  great  sensitiveness  to  the  open  nir. 
Severe  pain  in  the  head  and  eyeballs,  aggravated  by  motion 
{bry. ).  The  top  of  the  head  feels  as  if  it  would  fly  off  {bapt ). 
Chilliness  with  aching  pain  in  the  limbs.  Excessive  muscular 
soreness  {am.).  Cough  excited  with  every  attempt  to  speak 
{phos. ).    Alternate  constipation  and  diarrhea  {bry. ). 

Cina. — Violent  sneezing.  The  child  dont  want  to  be  touched. 
Dry,  hacking  cough  at  night  Gagging  cough  in  the  morning 
after  rising.  White  turbid  urine.  Worm  affections  {chenop., 
mere). 

Coninm. — Burning  in  the  eyes.    Hacking,  almost  constant. 


a 
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M 


S64 


LECTUHE8  ON  FEVERS. 


oougli;  worse  at  night  when  lying  down  (hyos.).  Palpitation  of 
the  heart  after  drinking.  Intermittent  flow  of  urine.  Exhaus- 
tion  and  faintness.     In  aged  persons. 

DrOMera. — Pressing  headache  in  the  temples.  Hoarseness 
with  oppression  of  the  chest,  worse  from  talking  (cnuaL,  phos.). 
Barking  cough  {rumex).  Cough  with  vomiting  {ipecac,  invt. 
emct. ).  Rheumatic  i)ain  in  the  arms,  at  night  Patient  supports 
the  chest  with  the  hands  {<mpat  V 

Eryngluin. — Severe  headache  with  fluent  coryza.  Raw,  smart- 
ing, burning  sensations  in  the  throat  and  larynx.  Irritating 
cough  with  expectoration  of  tenacious  yellow  mucus. 

Eiipatoriiini  perf. — Coryza,  with  sneezing,  hoarseness  and 
aching  pains  all  over  as  if  bruised  {am.).  Headache  with  pain 
and  soreness  of  the  eyeballs;  photophobia.  Cough  with  retch- 
ing {(Iros.).  Hacking  cough  in  the  evening,  with  soreness  in  the 
chest  (caus/.).  Cough  before  and  after  meals.  Intense  aching 
and  soreness  in  the  back  and  limbs  {am.).  Soreness  in  the  re- 
gion of  the  liver  {bry.,  mere). 

Euphorbiuni.— Soreness  in  the  back  of  the  head.  Burning, 
as  from  a  flame,  from  the  throat  to  the  stomach.  Spasmodic 
cough,with  stitches  extending  from  the  pit  of  the  stomach  to  both 
sides  of  the  chest.  Dry,  hollow  cough  from  tickling  in  the  chest 
or  throat  Profuse  watery  diarrhea  with  colic  and  great  pros- 
tration.    Dysenteric  symptoms  {mei'C. ). 

Euphrasia.— Prof  use,  fluent  bland  coryza,  with  scalding  tears 
(opp.  ars. ) ;  aversion  to  light  Burning  in  the  eyes  with  lachry- 
mation.  Dull  frontal  headache  {mere).  Catarrhal  hoarseness 
( hepar).  Dry,  tickling,  laryngeal  cough  during  the  day,  relieved 
by  eating  and  drinking.     Cramp-like  pains  in  various  parts. 

Gelsemiam. — Chilliness  along  the  spine;  cannot  leave  the  fire 
without  feeling  chilly.  Sneezing,  with  tingling,  especially  in 
the  left  nostril  {graph. ).  Stoppage  of  the  right  nostril;  irritat- 
ing discharge  from  the  left  nostril  with  scalding  sensation. 
Sensation  as  of  a  band  drawn  tightly  around  the  head  above 
the  ears  {mere. ).  Bruised  feeling  in  the  eyes  {bry. ).  Shooting 
pains  in  the  ears  when  swallowing.  Sore  throat,  with  collection 
ot  mucus.  Hard,  painful  cough  with  soreness  in  the  chest 
l^euralgic  and  rheumatic  pain  in  the  extremities  {cimicifuga^ 


J!^v;^iM-*^V■■v-,•-i■«SiaiS'J.fc^li:■«.:^ 


W^M 


M 


II  iiii  I M  B»aii*aisiBi';aii  i ' i  i  j 


LEAHINO   INDICATIONH. 


265 


rhnn).  Copious  discharge  of  limpid  urine  relievMig  the  head- 
Bclie  {phoa.  acid).  Liubility  to  take  cold  from  every  change  in 
the  weather  {dulc). 

Hepar  sulph.— Tensive  headache  above  the  nose  {mere).  In- 
flammation of  the  nose;  coryza;  acuteiiess  of  nense  of  smell. 
Darting  pains  in  the  ears,  with  cracking  noises  when  blowing  the 
nose.  Feeling  of  sand  in  the  eyes  {mlph.).  Roughness  and 
acraping  sensations  in  the  throat  (nnx).  Cough  with  constant 
lioarseness.  Sensation  as  of  a  fishbone  in  the  throat  {nit.  aciil). 
Cough  caused  by  uncovering  any  part  of  the  body  {rhns).  Lar- 
yngo-tracheal  catarih.  Great  desire  for  acids,  especially  vinegar 
(6rt/.,  nnx). 

Hydrastis. — Dull,  heavy  frontal  headache  {more. ).  Sneezing, 
with  fullness  over  the  eyes,  and  profuse  secretion  of  tears 
(euph.).  Copious  discharge  of  thin  watery  mucus,  with  smart- 
ing and  rawness  in  the  nose,  worse  in  the  open  air.  Rawness, 
soreness  and  burning,  in  the  throat  and  chest  {mere.  cor.,).  Dry, 
harsh,  rattling  from  tickling  in  the  larynx.  Great  weakness  and 
prostration.     In  weak  and  debilitated  individuals. 

Hyoscyamus. — Pressing  pinching  at  the  root  of  the  nose  and 
malar  bones.  Dry,  spasmodic  cough,  worse  at  night  and  on  ly- 
ing down,  relieved  by  sitting  up  {imls.).    In  old  persons. 

Iodine. — Dry  coryza,  becoming  fluent  in  the  open  air.  Ca- 
tarrhal deafness.  Hoarseness  with  constant  hemming  and  hawk- 
ing. Dry,  morning  cough  from  tickling  in  the  larynx  and  burn- 
ing in  the  chest.  Swelling  of  the  cervical  and  bronchial  glands. 
Progressive  emaciation. 

Ipecaciianlia. — Coryza  with  stoppage  of  the  nose.  Incessant, 
dry,  titillating  cough  with  dyspnoea.  Rattling  of  mucus  in  the 
chest.  Pale  face,  with  blue  margins  around  the  eyes.  Inde- 
scribable  sick  feeling  in  the  epigastric  region.  In  delicate  chil- 
dren. 

Iris  vers. — Constant  sneezing  with  neuralgia  of  the  head, 
«yes  and  temples.  Headache  with  blurred  vision.  Dull,  heavy 
throbbing  pains  in  the  forehead  and  right  temple  {bry.).  Dry, 
tickling  cough  with  smarting  and  burning  in  the  throat.  Taste- 
less or  acid  eructations.  Light,  mushy,  painless  stools.  Burn- 
ing in  the  anus  as  if  on  fire  after  stool.  Severe,  shooting  pains, 
especially  in  the  small  joints. 


I 


260 


LECTUI1E8  ON  FEVEItS. 


Kail  biell.  Frontnl  hemlncho,  uHually  ovor  one  eye  (HrtN//.). 
Lateral  luMulacho  in  Hiiiall  HpotH.  Fluent,  acrid  coryza,  excoriat- 
ing tlie  noHo  anil  lipH  {(initti,  mere,  cor.,).  BenHation  as  of  a  hair 
in  tlio  noHo  (liijilr(tati>i).  CEdumatoua  swelling  of  the  eyelids 
{ajm).  Prossive  pain  at  the  root  of  the  nose.  Ticl<ling  in  the 
larynx  causing  coughing.  Rattling  cough  with  viscid  stringy 
expectoration.  Hoarseness  in  the  morning  {cav8i.).  Feeling  of 
coldness  in  the  stoinacli  and  bowels.  Lameness  iu  the  right  arm; 
wandering  pains  (jmls.).  i 

Kali  liyd. — Violent  sneezing,  and  running  of  acrid  water  from 
the  nostrils  {allium).  Bensation  of  fullness  and  tightness  at  the 
root  of  the  nose,  with  tiirohbing  and  burning  pains  in  the  nasal 
and  frontal  bones  (kali  hicli. ).  Burning  in  the  eyes  with  profuse 
lachrymation.  Rawness  in  the  larynx;  stitches  from  the  ster- 
num to  the  back.  Bhort,  dry,  hacking  cough  Avith  whitish  and 
greenish  expectoration. 

Lachesis. — Fluent  coryza  and  lachrymation  (ars.,  kali  hyd.) 
Dryness  of  the  mouth  witli  burning  as  from  pepper.  Throat 
sore,  especially  when  touched  (apis).  Frontal  headache  with 
trifling  discharge  from  nostrils.  As  soon  as  a  profuse  ilischnrge 
sets  in  the  head  and  throat  8ymi)tom8  ameliorate.  I'ain  in  the 
left  ear  when  swallowing.  Dry,  spasmodic,  nightly  cough,  ag- 
gravated by  sleep.  Gagging,  persistent  cough  from  tickling  in 
the  throat.  Stitching  pain  in  hemorrhoidal  tumors  when  cough- 
ing or  sneezing. 

Lycopodinm. — Catarrh  of  the  frontal  sinuses;  pressing  or 
tearing  frontal  headache,  especially  in  the  right  side  of  the  head. 
Redness  of  the  eyelids  with  lachrymation.  Violent  coryza  with 
acrid  discharge  (arum,  mere).  Accumulation  of  mucus  in  the 
throat.  Lemon-colored  expectoration.  Sore,  pressive  pain  in 
the  region  of  the  liver  (chel).  Swelling  of  the  cervical  glands 
(were).  Dry  cough  day  and  night  as  if  from  fumes  of  sulphur 
in  the  larynx.    Hepatization  of  the  lungs  (hry.,  phos.). 

Mercurius. — Frequent  sneezing  with  prof  use,  fluent,  corrosive 
coryza  (arum,  kali  hyd.).  Burning  in  the  eyes  and  profuse  flow 
of  tears.  Catarrhal  headache.  Inflamed  and  ulcerated  tonsils 
(bell,  hepar).  Hoarseness  with  rawness  and  tickling  in  the 
larynx  (phos. ).    Rheumatic  pains  with  sore  throat,  not  relieved 


imm 


I  Olio  (3yo  (mtlf/.). 

koryzn,  oxcDiiut- 
Jition  nn  of  a  Imir 
[g  of  tho  eyelids 
Tickling  in  the 
111  viHcid  Htrini^ 
hsl).  Feolingof 
jiu  the  right  arm; 

iicrid  wator  from 
tightnPHH  ftt  the 

aiiiH  in  tJio  niisnl 

yes  with  prof  uHe 
from  the  ster- 

ith  whitish  and 

{(ira.,  kulihyd.) 
pepper.  Throat 
1  hendaciie  with 
rofiise  dischnrge 
ute.  Pain  in  the 
jhtly  cough,  ag- 
from  tickling  in 
lors  when  ouugh- 

ses;  pressing  or 
side  of  the  head, 
(lent  coryza  with 
of  mucus  in  the 
>ressive  pain  in 
>  cervical  glands 
imes  of  sulphur 
phos. ). 

fluent,  corrosive 
nd  profuse  flow 
Icerated  tonsils 
tickling  in  the 
•at,  not  relieved 


LEADINU  INDICATIUNH. 


2(57 


by  sweating.  Stitches  in  the  right  side  of  the  cliPBtwhen  siieez- 
ing  or  coughing  (hri/,).  Violent  night  cough.  I'lying  paiiw  in 
all  parts  of  the  lM)dy  from  coughing.  Constipation,  «w  iiiucuh, 
hilioui'i  diarrhc^a.  Violent  and  coimtant  thirst  for  cold  drinks. 
Ill  children  and  old  people. 

Nlix  voni. — Coryza,  fluent  in  tho  morning  and  during  the  day, 
but  dry  at  night.  Dry,  racking  cough  with  h(>adache  as  if  the  Hkull 
would  hurst;  great  Boreness  of  the  epigastrium.  Coryza  with 
sneezing,  worse  in  tho  morning  and  after  eating.  Boar  tasto  in 
the  mouth  every  morning  (hry.).  Great  debility  with  over-sen- 
sitiveness of  all  the  senses  {cinch.).  Drowsiness  in  the  day- 
time and  after  eating. 

Phellandriiim. — Headache,  with  pain  as  from  a  weight  (m  the 
top  of  the  head;  aching  and  burning  in  tho  temples  iihovo  the 
eyes.  Pain  in  tho  eyes  with  lachrymation,  photophobia  and  con- 
junctivitis. Hoarseness  with  roughness  in  the  throat  {hcpar). 
Dry  cough  with  shortness  of  breath  and  stitches  in  tho  cliesi 
Scanty  urination  with  violent  burning  after  a  discharge. 

PhosphoniH. — Throbbing  headache;  headache  over  tho  left 
eye  (aconile);  worse  in  tho  evening.  Frequent  sneezing,  with 
alternately  fluent  and  dry  coryza.  Nose  swollen,  dry  and  stopped 
up.  Diflicult  hearing,  especially  of  the  human  voice.  Hoarse- 
ness and  roughness  of  the  voice  (catisL,  hepar).  Dry,  tickling 
cough  with  tightness  across  the  chest,  relieved  by  pressure  upon 
the  external  walls.  Cough  worse,  before  midnight,  from  re.iding, 
laughing  or  speaking,  and  on  going  into  the  cold  air  {hry,, 
rumex);  better  after  sleeping  (opp.  Inch.).  Mucous  rales  in 
both  lungs,  especially  in  the  lower  lobes  {ipecac,  tart.  emei,). 

Phytolacca.  — Pressive,  sore  pain  in  the  forehead,  worse  on 
the  right  side.  Sensation  of  soreness,  deep  in  the  brain.  Burn- 
ing, smarting  in  the  eyes,  with  lachrymation.  Thin,  Avatery  dis- 
charge from  one  nostril  with  stoppage  of  the  other  (gels.,  sepia). 
Drawing  sensation  about  the  root  of  the  nose.  Great  pain  in 
the  root  of  the  tongue  when  swallowing.  Excruciating  pain 
through  both  ears  when  swallowing.  Dry,  hacking  cough,  with 
hawking,  excited  by  tickling  in  the  larynx  and  dryne.-is  in  the 
pharynx.  Rheumatic  pains  in  the  extremities.  Derangement 
of  the  digestive  organs. 


1^ 


'MiHtfWWUlgrtif 


K«»»««anAMMwniaMiMOVi«u<L-w«)i7 '  •■ 


'Hi 


K 


LECTURES  ON  FEVIIRS. 


Pulsatilla.— Bursting,  throbbing  headache  in  the  forehead 
and  temples,  relieved  by  pressure  (apis).  Fluent  or  dry  coryza, 
with  frequent  sneezing,  and  loss  of  taste  and  smell  {aulph.). 
Stoppage  of  the  nose  in  the  evening  and  in  a  warm  room.  In- 
flammation of  the  eyes  with  profuse  lachrymation  (euph.). 
Darting,  tearing,  pulsating  pains  in  the  ear  at  night  (mere). 
Koaring  in  the  ears,  as  if  from  the  rushing  of  waters.  Dry  cough, 
at  night  or  in  the  evening,  especially  after  lying  down  (hyos.). 
Loose  cough,  with  vomiting  of  mucus,  and  nightly  diarrhea. 
Aversion  to  fat  food  (opp.  mix).  Gastric  disturbance  from  rich 
food  or  pastry  (nwa*).  Drawing,  tearing  pains  frequently  shift- 
ing from  one  part  of  the  body  to  another  (kali  hich. ).  Especially 
adapted  to  females  and  children. 

Bhiis  tox. — Frequent,  violent,  spasmodic  sneezing.  Hot,  acrid 
discharge  from  the  nose.  Aching,  pressive  pains  in  the  eyes 
(canst);  oedema  of  the  lids  (apis).  Swashing  and  jarring  sen- 
sations in  the  brain  (nairum).  Short,  diy  cough  from  tickling 
in  the  bronchi  (rumex).  Putting  the  hands  out  of  bed  brings 
on  the  cough  (hepar).  Pain  and  aching  in  the  limb<=t,  worse 
during  rest,  better  during  exercise.  Great  restlessness,  must 
change  position  often  (opp.  bry.).     Typhoid  symptoms. 

Rumex  crisp. — Fluent  coryza,  with  violent  sneezing,  and  pain- 
ful irritation  of  the  nostrils;  worse  towards  evening  and  at  night. 
Dry,  scraping  sensation  in  the  throat,  with  copious  secretion  of 
mucus  in  posterior  nares.  Hoarseness,  with  pain  and  rawness  in 
the  larynx  (phos.).  Violent,  dry  cough,  excited  by  tickling  in 
the  larynx  (sang.),  often  almost  continuous;  worse  at  night  from 
exposure  to  cool  air,  and  on  lying  down  (dros.,  pJios.).  Brown 
and  watery  morning  diarrhea  (sulph.).  Great  debility,  with 
restlessness  and  extreme  sensibility  to  the  open  air  (rhus). 

Sabadilla.  —Headache,  with  fluent  coryza.  Lachrymation, 
with  redness  of  the  ey  -s.  Chilliness,  with  heat  and  redness  of 
the  face.  Cough  worse  on  lying  down  ( %os.,  lack.).  Burning 
and  stitches  in  the  chest.  Bed  spots  on  the  chesi  Pain  in  the 
bones  as  if  scraped  (rhus).  Debility,  with  heaviness  and  relax- 
ation of  the  body.  Aggravation  of  svmptoms  at  the  same  hour 
€very  day  (cedron), 

Sanguinaria. — Fluent  coryza,  with  frequent  sneezing  (eu- 
phrasia).    Smell  in  the  nose  like  roasted  onion.    Circumscribed 


immm 


the  forehead 
)r  dry  coryza, 
lell   {sulph.). 
n  room.     In- 
ion    (euph.). 
light  {mere). 
Dry  cough, 
own  (hyos.). 
itly  diarrhea, 
ince  from  rich 
quently  shift- 
Especially 

ag.  Hot,  acrid 
IS  in  the  eyes 
d  jarring  sen- 
from  tickling 
of  bed  brings 
e  limb«.  worse 
essness,  must 
>toms. 

zing,  and  pain- 
g  and  at  night. 
18  secretion  of 
md  rawness  in 
.  by  tickling  in 
i  at  night  from 
Jios. ).  Brown 
debility,  with 
ir  (rhus). 

Lachrymation, 
and  redness  of 
3^).  Burning 
t  Fain  in  the 
Dcss  and  relax- 
the  same  hour 


sneezing  (cm- 
Circumscribed 


LEADING   INDICATIONS. 


269 


redness  of  the  cheeks.  Looseness  of  the  teeth  with  ptyalism 
{mere).  Feeling  of  dryness  in  the  throat;  constt^nt  tickling  at 
the  entrance  of  tV>ci  larynx;  ulcerated  sore  throat.  Catarrhal 
affections  of  the  inner  ear  and  Eustachian  tube.  Wheezing  cough, 
worse  at  night.  Dry,  hacking  cough  from  tickling  in  the  throat- 
pit  {rumcx).  Severe  and  persistent  dyspnoea,  with  inclination 
to  take  deep  inspirations.  Diarrhea  following  the  coryza,  and 
relieving  the  cough.  Desire  for  piquant,  highly  seasoned  food. 
Wandering  rheumatic  pains,  worse  at  night  and  from  motion. 
Fneumonia  with  extensive  hepatization  {phos. ). 

8anguinaria  nitrate. — Violent  sneezing  with  profuse  watery 
discharge  from  the  nostrils  {euph.).  Burning  pain  and  rawness 
in  the  nose  {ars.).  Hoat  and  burning  in  the  eyes,  with  dimness 
of  sight,  and  profuse  lachrymation.  Sore,  aching  pain  in  the 
right  eyeball,  extending  into  the  supra-orbital  region.  Burning 
pain  in  the  forehead  and  at  the  root  of  the  nose.  Catarrhal 
affections  of  the  internal  ear  and  Eustachian  tube.  Soreness  and 
roughness  of  the  throat,  with  sense  of  constriction  and  difficulty 
of  swallowing.  Accumulation  of  mucus  in  the  throat  and  chest 
{kali  bich.).  Tension  and  burning  behind  the  sternum  with  de- 
sire to  cough  {rumex).  Cough  with  expectoration  of  large 
quantities  of  thick,  yellow,  sweetish  mucus.  All  the  symptoms 
are  worse  at  night  {mere). 

Senega. — Aching  pain  and  tension  in  the  eyeballs.  Weakness 
of  the  eyes  with  bumip^  and  lachrymation.  Acuteness  of  the 
sense  of  hearing  {cann.  ind. ) .  Dry.  shaking  cough  from  tickling 
in  the  larynx.  Battling  cough  with  profuse  secretion  of  mucus 
{Jtaii.  emet).  Cough  with  expectoration  of  slate-colored  mucus. 
In  old  people. 

Sepia. — Fluent  coryza  with  frequent  sneezing  {allium, sang.). 
Obstruction  of  the  nose  and  violent,  dry  coryza.  Swelling  and 
redness  of  the  eyes,  with  lachrymation,  worse  morning  and 
evening,  better  during  the  day.  Intense  frontal  headache.  Her- 
petic eruptions  on  the  lips.  Painful  sensation  of  emptiness  in 
the  stomach  and  abdomen  {hyd.,  ignat. ).  Hoarseness  with  cough 
from  tickling  in  the  larynx  {hepar,  phos.).  Dry,  tickling  i  ough 
at  night  {hyos.),  followed  by  expectoration  of  mucus  with  tem- 
porary relief  {ipecac).    Morning  cough,  with  greenish,  salty 


■MM 


^70 


LECTURES  ON  FEVERS. 


expectoration.     Stitches  in  the  chest  when   coughing   {hry.). 
Pain  in  the  chest  relieved  by  pressure  (opp.  calcarea). 

Silphiiim. — Sneezing,  with  discharge  of  acrid  mucus  from  the 
nose.  Scraping,  tickling  sensations  in  the  throat.  Tightness  of 
the  chest;  spasmodic  cough;  copious  expectoration  of  yellow 
mucus.  Profuse  expectoration  of  water  mixed  with  light-col- 
ored, stringy,  tasteless  mucus. 

Spigelia. — Fluent  coryza,  with  dry  heat  and  no  thirst.  Burn- 
ing pain  in  the  right  side  of  the  head  extending  into  the  eye. 
Hyperaesthesia  of  the  fifth  nerve.  Otalgia  with  pressive  pain  as 
from  a  plug.  Toothache  aggravated  by  cold  air  or  cold  water 
(opp.  coffea).  Dry,  hard,  night  cough  with  dyspnoea.  Headache 
with  hoarseness;  anxiety  with  palpitation  of  the  heart. 

Spongia. — Fluent  coryza  with  frequent  sneezing  (allium, 
sang.).  Dry  coryza  with  stoppage  of  the  nose  (nux).  Pain  iu 
the  chest,  with  rawness  in  the  throat  when  coughing.  Dry,  hol- 
low, barking  or  wheezing  cough,  relieved  by  eating  or  drinking. 
Hoarseness;  larynx  sensitive  to  the  touch  (lack.).  Swelling  of 
the  sub-maxillary  glands  (mere.). 

Stannum.  -Dry  coryza;  stoppage  high  up  in  the  nose  (lye). 
Neuralgic  headache;  the  pains  commence  lightly,  increase  grad- 
ually to  a  high  degree,  and  decrease  again  as  slowly.  Dryness 
and  rawness  of  the  throat.  Hoarseness  and  roughness  in  the 
larynx  {phos. ).  Scraping  cough  with  profuse  greenish,  sweetish 
expectoration.  Feeling  of  great  weakness  and  exhaustion  in  the 
cliest.  Faintness  with  weakness  of  the  voice,  worse  from  sing- 
ing or  talking  (arum). 

Sticta. — Incessant  sneezing,  with  a  feeling  of  fullness  in  the 
riglit  side  of  the  forehead  down  to  the  root  of  the  nose,  with 
tingling  in  the  right  nostril.  Splitting  frontal  headache.  Dry, 
racking  cough  in  the  evening  and  at  night,  excited  by  inspiration. 
Cough  from  tickling  in  the  right  side  of  the  trachea,  with  op- 
pression of  the  chest.  Excessive  dryness  of  the  mucous  mem- 
brane. All  symptoms  worse  in  the  afternoon;  better  in  the 
morning  and  in  the  open  air.     Sleeplessness. 

^lulphur. — Fluent  coryza;  coryza  with  stoppage  of  the  nosa 
Itching  and  burning  in  the  nostrils,  as  if  sore.  Dry  ulcere  or 
scabs  in  the  nose.    Stitches  in  the  throat  when  swallowing  (bell). 


■m 


HYGIENIC  AND   DIETETIC  TREATMENT. 


271 


Ighing   (bry.). 
p'ea). 

lucuB  from  the 
Tightness  of 
lion  of   yellow 
rith  light-col- 
thirst.    Bum- 
g  into  the  eye. 
ressive  pain  as 
or  cold  water 
toea.  Headache 
heart. 

ezing  (allium, 
mix).  Pain  iii 
ing.  Dry,  hol- 
ng  or  drinking. 
Swelling  of 


;he  nose  {lye). 
,  increase  grad- 
owly.  Dryness 
ugliness  in  the 
jenish,  sweetish 
haustion  in  the 
>rse  from  sing- 
fullness  in  the 
the  nose,  with 
eadache.  Dry, 
by  inspiration, 
ichea,  with  op- 
mucous  mem- 
;  better  in  the 

ge  of  the  nosa 

Dry  ulcere  or 

allowing  (6eW.). 


Dry  cough  in  the  eveninj,'  on  lying  down,  with  itching  in  the 
bronchi.  Stitches  in  the  chest  extending  back  to  the  left  scapula 
( kali  carb. ).  Chronic  cough  with  mucous  rales.  Sudden  arrest 
of  breathing  when  turning  in  bed.  Tearing  pains  in  the  limbs, 
muscles  and  joints  from  above  downward  (opp.  ledum).  Morning 
di>ivriiea,  driving  the  patient  out  of  bed  hurriedly, 

Tartar  emet. — Chilliness,  with  sneezing,  fluent  coryza  and 
loss  of  taste  and  smell.  Much  rattling  of  mucus  in  the  chest 
(ipecac).  Oppression  of  breathing,  relieved  by  expectoration. 
Cough  followed  by  yawning  (nux),  especially  in  children.  Great 
restlessness.  The  child  must  be  carried,  it  cries  if  touched 
(cham.,  staph.).     Gastric  symptoms.     Cyanosis  (cujirum). 

Teratmni  alb. — Icy  coldness  of  the  forehead  and  nose.  Smell 
as  of  smoke  before  the  nose;  painful  dryness  of  the  nose;  fre- 
quent, violent  sneezing.  Difficult  respiration  with  tightness 
and  constriction  in  the  chest.  Deep,  hollow  cough,  occurring 
in  shocks.  Icy  coldness  of  the  extremities.  Sudden  sinking  of 
strength  (ars.).  Capillary  bronchitis  (chel);  oedema  of  the 
lungs  (moschus). 

Wyethia. — Dryness  of  the  throat.  Burning  and  tickling  in 
the  epiglottis.  Dry,  hacking  cough,  caused  by  tickling  in  the 
epiglottis.  Pain  in  the  forehead  over  the  right  eye.  Sharp  pain 
and  soreness  in  the  right  hypochondrium.  Diarrhea  with  dark 
brown  evacuations. 

HYGIENIC   AND   DIETETIC   TREATMENT. 

Individuals  suffering  from  an  attack  of  influenza  should  remain 
indoors.  The  diet — from  which  meat  must  be  excluded — should 
be  plain  and  easily  digested.  The  various  fruit  syrups  may  be 
used  as  drink  in  n  oderate  quantities.  Weak  wine-whey  is  fre- 
quently useful.  "V^hen  the  stomach  is  irritable  koumyss  will 
prove  grateful.  Sound  claret  may  be  allowed,  if  desired  by  the 
patient.  Free  inunctions  about  the  brow  and  over  the  bridge  of 
the  nose,  are  of  service  when  the  coryza  is  excessive.  When  the 
head  pains  are  severe,  warm  applications  or  a  flannel  cap  may 
be  used.  The  tickling  cough,  which  is  ofttimes  very  annoying, 
may  be  allayed  to  a  considerable  extent  by  resorting  to  steam 
inhalations. 


mm 


J 


:>l 


LECTURE  XVIIL 

Typhus  Fever, 

You  will  doubtless  remember  that  I  completed  the  history  of 
the  miasmatic-contagious  fevers  at  my  last  lecture.  To-day,  I 
will  commence  the  history  of  the  third  class  of  fevers — the  con- 
tagious fevers.    The  first  in  order  in  this  class  is  Typhus  Fever. 

Definition. — Typhus  fever  may  be  defined  as  an  acute,  highly 
contagious  fever,  having  an  average  duration  of  fourteen  days, 
due  to  an  unknown  specific  poison,  arising  usually  in  connec- 
tion with  overcrowding,  imperfect  ventilation  and  filth,  and  oc- 
curring in  more  or  less  extensive  epidemics.  It  is  characterized 
by  sudden  invasion,  usually  with  a  chill;  great  and  early  pros- 
tration; deeply  flushed  face:  frontal  headache;  injected  eye; 
pain  in  the  back  and  thighs;  pungent  heat  of  the  skin,  with  an 
ammoniacal  odor;  mulberry-rash  on  the  fifth  day,  first  on  the 
sides  of  the  chest  or  abdomen^  frequently  becoming  petechial 
on  the  eighth,  ninth  or  tenth  day;  furred  tongue;  usually  con- 
stipation with  flat  or  even  scaphoid  abdomen;  a  high  temperature 
and  a  quick  pulse;  after  the  first  week,  delirium;  stupor  or  coma; 
a  dry  and  bro^^ii  tongue;  tremors  and  involuntary  discharges. 
Death  may  take  place  from  either  coma  or  syncope,  or  as  a  result 
of  complications.  No  constant  specific  lesions  are  found  upon 
examination  after  death.  Eelapses  are  infrequent;  a  second 
attack  is  of  rare  occurrence.  The  incubation  is  from  five  to 
fourteen  days. 

Synonyms. — It  has  been  known  and  described  as:  Infectious 
fever.  Ship  fever.  Emigrant  fever.  Contagious  fever.  Pesti- 
lential fever.    Petechial  fever.    Putrid  continued  fever.    Epi- 

(272) 


1 


(MMM 


wssmsf. 


ss^ 


ed  the  history  of 
iture.  To-day,  I 
fevers — the  con- 
is  Typhus  Fever. 

an  acute,  highly 
f  fourteen  days, 
lually  in  connec- 
md  filth,  and  oc- 
;  is  characterized 
i  and  early  pros- 
e;  injected  eye; 
he  skin,  with  an 
day,  first  on  the 
oming  petechial 
fue;  usually  con- 
ligh  temperature 
;  stupor  or  coma; 
itary  discharges. 
>pe,  or  as  a  result 
3  are  found  upon 
iquent;  a  second 
I  is  from  five  to 

3d  as:  Infectious 
)us  fever.  Pesti- 
ixed  fever.    Epi- 


OEOaRAPHICAL  LIMITS. 


278 


demic  fever.     Camp  fever.     Malignant  hospital  fever,  and  Irish 
ague. 

History. — Although  the  description  given  by  Thuycidides,  of 
a  pestilential  fever  which  prevailed  in  Athens  at  the  time  of  the 
Peloponnesian  war,  resembles  in  outline  that  of  typhus  fever, 
the  first  satisfactory  account  on  record  is  that  given  by  Fracas- 
torius  in  1501,  of  a  disease  which  spread  from  Cyprus  into  Italy 
nnd  o'.  erran  all  Europe,  and  had  prevailed  for  over  twenty  years. 
Durii  tij  the  sixteenth  century  many  accounts  were  published  of 
deb!  uctive  epidemics  that  prevriled  in  Tuscany,  Hungary  and 
Fran  je,  spread  all  over  the  continent,  and  extended  to  Great 
Britain  and  Ireland. 

Between  the  years  1609  and  1638,  all  Europe  was  devastated 
by  famine  and  by  a  contagious  fever  which  resembled  typhus. 

The  great  plague  of  London  in  1665  was  preceded  and  fol- 
lowed by  a  continued  fever,  which  bore  a  striking  resemblance 
to  typhus.  In  Ireland  the  disease  was  described  as  the  "Irish 
Ague."  About  the  beginning  of  the  last  century,  a  continued 
fever  resembling  typhus  spread  throughout  Europe  and  the 
British  Isles,  and  was  most  prevalent  in  over-crowded  localities. 
From  1735  to  1803  several  severe  and  fatal  epidemics  appeared 
in  Ireland,  and  extended  into  various  parts  of  England.  From 
1816  to  1819  wide-spread  epidemics  occurred  in  Ireland  and  in 
Northern  Italy,  while  limited  epidemics  appeared  in  different 
parts  of  Europe.  During  the  six  years  following  1826  it  was 
endemic  in  Great  Britain  and  Ireland,  but  became  again  epi- 
demic in  1842  and  1846.  Wide-spread  epidemics  appeared  in 
Ireland,  Bussia  and  Prussia,  in  1847, 1857  and  1868.  From  1854 
to  1856  typhus  prevailed  very  extensively  among  the  armies  in 
the  Crimea. 

Be&tricted  epidemics  have  appeared  on  this  continent  since 
the  beginning  of  the  present  century.  The  first  epidemic  broke 
out  in  the  Boston  poorhouse,  in  1816.  Since  that  time  it  has 
repeatedly  appeared  in  consequence  of  direct  importation.  It 
has  raged  on  several  occasions  at  New  York,  particularly  in  1818, 
1825,  1827  and  1861-65.  It  appeared  at  Buffalo  in  1850-52,  and 
at  Philadelphia  in  1820,  1836, 1864  and  1880. 

Geographical  Limits. — The  chief  geographical  center  of  ty- 
phus fever  is  Ireland.     Other  centers   are  found  in  Northern 


■iWi>Hlft««'i  Wigw 


274 


LEOTUItES  ON  FEVEIIS. 


R;i 


Italy,  and  the  Baltic  provinces  of  Russia.  The  disease  has 
spread  from  these  centers  throughout  Europe,  Asia  and  the 
British  Isles;  and  has  been  observed,  under  circumstances  of 
direct  importation,  principally  in  the  coast  cities  of  the  Northern 
States  of  this  country,  in  the  neighboring  Dominion  of  Canada 
and  in  the  West  Indies.  It  has  not,  as  yet,  been  observed  in  the 
Southern  States,  Africa  or  Australia. 

Etiology. — The  causation  of  typhus  fever  may  be  conven- 
iently studied  under  the  two  divisions,  predisposing  and  exciting 
causes. 

1.  The  Predisposing  Causes. — Of  the  predisposing  causes, 
over-crowding,  filth  and  starvation  are  the  most  important.  The 
majority  of  the  great  epidemics  of  typhus  have  generally  oc- 
curred in  times  of  scarcity  among  the  poor  and  under-fed  of 
large  cities,  living  huddled  together  in  crowded  and  illy-venti- 
lated apartipen:ts.  Fatigue,  want  of  sleep,  frequent  exposures, 
previous  illness,  anxiety  and  other  depressing  emotions  materi- 
ally predispose  to  the  disease.  Hence  medical  students,  hospital 
internes,  nurses,  nervous  people  and  individuals  recovering  from 
even  slight  illness,  not  infrequently  contract  typhus  fever.  Ty- 
phus is  for  the  most  part  a  disease  of  adult  years,  although  all 
periods  of  life  are  liable  to  its  attacks.  It  is  essentially  a  dis- 
ease of  cold  and  temperate  climates,  and  is  most  prevalent  dur- 
ing tho  winter  months.  Damp  or  marshy  soil  favors  its  devel- 
opment. 

2.  I'he  Exciting  Cause. — The  nature  of  the  exciting  cause  of 
typhus  fever  remains,  as  yet,  unknown.  The  majority  of  observ- 
ers, however,  agree  in  describing  the  infecting  principle  as  an 
organized  germ,  emanating  from  the  body  of  an  affected  individ- 
ual, and  capable  of  indefinite  reproduction.  And  careful  clinical 
observation  has  established  the  fact  that  this  specific  typhus 
poison  may  be  communicated  directly  from  the  sick  to  the  heal- 
thy in  the  expired  air,  and  in  the  cutaneous  exhalations  of  pa- 
tients. The  peculiar  pungent  odor  conveyed  by  the  l>  eath  and 
emitted  from  the  bodies  of  typhus  patients  is,  as  a  rule,  strong 
in  proportion  to  the  intensity  of  the  poison.  The  germs  are 
believed  by  many,  capable  of  retaining  their  vitality  for  a  great 
length  of  time,  and  of  being  carried  in  the  bedding  and  in  the 
clothing  of  patients,  which  act  as  fomites.     In  this  way  it  is 


-~I%<s<<aia>3n&«lWUeM4««ttU4iaiS«l»iiW 


ETIOLOOV. 


275 


The  disease  has 
jpe,  Asia  and  the 
r  circumstances  of 
ies  of  the  Northern 
>minion  of  Canada 
jen  observed  in  the 

sr  may  be  conven- 
posing  and  exciting 

redisposing  causes, 
ost  important.    The 
have  generally  oc- 
r  and  under-fed  of 
rded  and  illy-venti- 
frequent  exposures, 
ig  emotions  materi- 
•al  students,  hospital 
uals  recovering  from 
t  typhus  fever,    Ty- 
t  years,  although  all 
t  is  essentially  a  dis- 
most  prevalent  dur- 
loil  favors  its  devel- 

the  exciting  cause  of 
e  majority  of  observ- 
cting  principle  as  an 
)f  an  aflfected  individ- 
And  careful  clinical 
this  specific  typhus 
1  the  sick  to  the  heal- 
is  exhalations  of  pa- 
red by  the  b  eath  and 
ts  is,  as  a  rule,  strong 
jon.    The  germi*  are 
eir  vitality  for  a  great 
,e  bedding  and  in  the 
es.    In  this  way  it  is 


argued  that  housfes,  ships  and  hospital  wards  may  readily  become 
hot-beds  for  the  production  and  spread  of  the  disease.  Loomis, 
and  other  more  recent  writers,  however,  are  doubtful  whether  the 
disease  can  be  communicated  by  fomites  alone,  even  when  highly 
impregnated,  and  maintain  that  it  is  necessary  for  the  subject  of 
the  contagion  to  have  been  brought  in  ccmtact  witli  an  infected 
person,  or  within  the  atmosphere  immediately  impregnated  with 
his  exhalations.  The  contagious  distance  of  typhus  fever— the 
distance  at  which  the  specific  poison  may  be  transmitted  by  the 
breath  or  cutaneous  exhalations,  through  the  atmosphere,  in  the 
open  air-— is  somewhat  less  than  that  of  small-pox,  which  has 
been  demonstrated  by  actual  ^^xperiment  to  be  two  and  one-half 

feet. 

In  large  and  well-ventilated  apartments  the  risk  of  contagion 
is  greatly  lessened;  while  in  small,  badly-ventilated  rooms,  it  is 
largely  increased.  There  are  no  facts  to  prove  that  the  disease 
is  diffused  from  one  house  to  another  or  from  hospitals  to  ad- 
joining houses  except  by  intercommunication.  It  is  occasionally 
contracted  in  the  dissecting  room,  by  dissecting  bodies  dead 

with  typhus. 

The  danger  of  contagion  is  slight  during  the  first  week  of 
typhus,  but  is  largely  increased  from  the  close  of  this  period, 
until  convalescence  becomes  established.  In  the  majority  of  in- 
stances the  disease  attacks  an  individual  but  once.  All  persons, 
at  all  times,  are  not  equally  susceptible.  A  special  constitutional 
idiosyncrasy  occasionally  exists,  which  affords  an  immunity. 

The  length  of  the  period  of  incubation  varies  from  five  to 
fourteen  days. 

Summing  up  the  known  facts  in  the  etiology  of  this  fever,  we 
are  led  to  state: 

1.  That  there  exists  a  specific  typhus  poison,  which  is  undoubt- 
edly present  in  the  body  exhalations  and  in  the  expired  air  of 
typhus  patients. 

2.  That  it  is  communicated  only  by  personal  contagion— the 
contagious  distance  being  about  two  feet. 

3.  That  a  concentration  of  the  poison  is  necessary  to  produce 
the  infection,  and  that  where  there  is  tree  ventilation  personal 
contagion  is  confined  to  limited  areas. 

4.  That  it  in  taken  into  the  bmly  mainly  through  inspired  air. 
6.  That  over-crowding    and  deficient  ventilation,  even  when 


ftMrr 


IV 


276 


LECTURES   ON   FEVEllS. 


conjoined  with  innutrition,  do  not  produce  typhus,  but  favor,  by 
deteriorating  the  constitution,  its  extension  and  increase  its 
severity. 

6.  That  it  ordinarily  occurs  but  once  in  a  life  time. 

7.  That  in  this  country  it  is,  as  a  rule,  an  imported  disease. 

Clinical  History. — The  advent  of  typhus  fever  is  usually  ab- 
rupt. Occasionally  there  is  a  prodrorial  stage  of  a  few  days 
duration,  marked  by  general  lassitude,  headache,  anorexia,  ver- 
tigo and  nocturnal  restlessness.  In  a  majority  of  the  cases  there 
are  no  prodromes,  the  disease  being  ushered  in  by  a  short,  sharp, 
sudden  chill  or  by  chilly  sensations.  At  times  the  chill  or  chilly 
sensation  recurs  at  irregular  intervals  for  several  days;  and,  in 
children,  repeated  vomiting  not  unfrequently  occurs.  A  sense 
of  extreme  prostration  soon  follows  the  initial  chill,  attended,  os 
a  rule,  by  intense  and  steadily  increasing  frontal  headache.  Tlie 
fever  increases  rapidly,  and  the  temperature  may  rise  during  the 
first  twenty-four  hours  as  high  as  105°  Fahr.  or  106°  Fahr. 
Notwithstanding  the  high  temperature,  the  patient  frequently 
complains  of  a  sensation  of  coldness.  The  skin  becomes  hot,  the 
face  flushed,  the  eyelids  swollen  and  injected,  and  the  respira- 
tions slightly  hurried.  Occasionally  there  is  sneezing  with 
slight  cough  and  soreness  of  the  throat.  More  or  less  severe 
pain  in  the  back,  and  sore,  dull  pains  in  the  limbs,  especially  in 
the  thighs,  are  constantly  present.  The  tongue  is  at  first  pale, 
swollen,  and  covered  with  a  whitish  fur;  later  it  is  covered  with 
a  yellowish-brown  coating,  and  displays  a  tendency  to  become 
dry,  brown  and  fissured,  and  ofttimes  tremulous.  Nausea  is 
sometimes  present;  vos:.iting  rarely  occurs.  The  bowels  are,  as 
a  rule,  constipated,  e^xceptionally  there  is  slight  diarrhea.  The 
spleen  becomes  enlarged  early  in  the  disease,  and  there  is  slight 
tenderness  in  both  hypochondria. 

During  the  first  week  of  the  fever  the  temperature  varies  from 
103°  Fahr.  or  104°  Fahr.  in  the  morning,  to  104°  Fahr.  or  106° 
Fahr.  in  the  evening. 

The  pulse  is  accelerated  from  the  beginning  of  the  attack, 
ranging  from  100  or  110  in  the  morning,  to  120  or  130  in  the 
evening.  It  is  at  first  full,  but  soon  becomes  soft  and  compressi- 
ble; later  it  grows  feeble,  and  is  not  unfrequently  dicrotic.  As 
the  fever  progresses  the  expression  of  countenance  becomes  dull 


«!iw-<*JMWi.w«iK<eics«ic«s43»st;v-  r>,-«fimmismiimeaii)ts 


CLINICAL  HISTORY. 


277 


jh«8,  but  favor,  by 
and  IncrenBe  its 

|fe  time, 
iported  disease. 

fever  is  usually  ab- 

age  of  a  few  days 

ache,  anorexia,  ver- 

ty  of  the  cases  there 

n  by  a  short,  sharp, 

58  the  chill  or  chilly 

sveral  days;  and,  in 

ly  occurs.     A  sense 

fvl  chill,  attended,  as 

ntal  headache.   The 

may  rise  during  the 

ahr.  or  106°  Fahr. 

e  patient  frequently 

kin  becomes  hot,  the 

ted,  and  the  respira- 

re  is  sneezing  with 

More  or  less  severe 

I  limbs,  especially  in 

mgue  is  at  first  pale, 

ter  it  is  covered  with 

tendency  to  become 

emulous.     Nausea  is 

The  bowels  are,  as 

ight  diarrhea.     The 

e,  and  there  is  slight 

iperature  varies  from 
;o  104°  Fahr.  or  106° 

nning  of  the  attack, 
0  120  or  130  in  the 
3  soft  and  compressi- 
juently  dicrotic.  As 
^nance  becomes  dull 


and  stupid,  and  the  cheeks  assume  a  mahogany  appearance.  The 
sleep  is  disturbed,  and  between  sleeping  and  waking  there  is 
sliglit  delirium. 

Between  the  fourth  and  eighth,  usually  on  the  fifth  day,  the 
characteristic  eruption  appears,  first  upon  the  sides  of  the  chest 
and  abdomen,  gradually  extending  over  the  whole  anterior  por- 
tion of  the  body,  except  the  neck  and  face.  It  consists  of  nu- 
merous roseola-like  spots,  varying  in  size  from  a  mere  point  to 
three  or  four  lines  in  diameter,  and  is  more  marked  upon  the 
trunk  tlmn  on  the  extremities.  It  is  oftener  wanting  in  children 
than  in  adults;  in  the  former  it  frequently  resembles  the  erup- 
tion of  measles.  At  first,  the  spots  are  of  a  dark  red  or  dirty 
rose-color,  appear  slightly  raised  above  the  surface  of  the  sur- 
rounding skin,  and  temporarily  disappear  on  pressure.  After 
two  or  three  days  they  become  darker  in  color,  and  appear  as 
faint,  irregular,  dirty  brown  stains.  They  are  now  no  longer 
elevated,  and  do  not  entirely  disappear  on  firm  pressure.  A 
faintly  reddish  ill-defined  mottling  or  marbling,  appearing  as  if 
it  were  a  little  distance  below  the  surface  of  the  skin,  between 
the  spots  or  groups  of  spots  is  generally  present.  The  spots  and 
the  sub-cuticular  mottling  may  exist  separately  and  alone,  usu- 
ally they  occur  together  and  constitute  the  "  mulberry  rash  "  of 
typhus. 

The  course  of  the  eruption  is  typical.  The  rash  is  fully  de- 
veloped in  less  than  forty-eight  hours,  and  its  copiousness  rep- 
resents generally  a  corresponding  gravity  of  the  disease.  Each 
spot  or  patch  remains  visible  from  its  first  appearance  until  con- 
valescence is  established  or  death  takes  place.  In  a  certain  pro.- 
portion  of  cases  the  typhus  spots  become  petechial,  and  in  severe 
grades  of  the  fever  they  may  be  converted  into  dark  red  stains. 
This  occasional  change  in  the  character  of  the  eruption  has  led 
to  the  erroneous  title,  "  petechial  typhus." 

At  the  close  of  the  first  week  the  headache  disappears,  and 
delirium,  usually  low  muttering,  sometimes  acute  and  boisterous, 
comes  on.  Occasionally  the  delirium  is  active  and  persistent 
from  the  start,  and  physical  restraint  is  rendered  necessary. 
About  the  middle  of  the  second  week  as  the  sjmiptoms  continue 
to  deepen,  the  intense  nervous  excitement  abates.  The  patient 
now  becomes  drowsy,  passes  into  a  state  of  "  coma  vigil,"  and 
lies  for  hours  apparently  unconscious  with  the  eyes  open  as 


V- 


278 


LECTUREH  ON   FKVEna. 


thouyh  nwfike.  This  "  coma  vigil "  or  wntclif\il  'inmn  ih  n  stnte 
of  H[>{)Hi'eiit,  rathertlian  com plete  conm,  from  whir  li  the  patient 
can  l)o  easily  aroused.  It  is  usually  attended  with  !L,'roat  mental  ac- 
tivity,  and  in  of  unfavorable  omen.  Personf*  of  Jictive  l»rain  fre- 
(luently  have  the  most  distreHHing  fancies  during  this  period.  If 
the  case  terminates  in  recovery  the  patient  emerges  with  a  dis- 
tinct remembrance  of  all  the  horrid  visions  that  passed  before  his 
imagination.  At  this  stage  of  the  fever  the  face  ajjpears  llushed, 
tlie  c(mjunctiva)  are  injected,  and  there  is  a  dusky  pallor  alxiut 
the  nostrils  and  lips.  The  pains  in  the  limbs  and  back  are  no 
longer  comjjlained  of,  and  involuntary  twitcliings  occur.  The 
respirations  become  quickened,  ami  there  is  a  dry,  annoying 
cough  with  scanty  raucous  expectoration.  The  breath  and  cuta- 
neous exhalations  give  off  an  ammoniacal  or  "  monseMUe  "  odor. 
The  lieTt-sounds  become  feeble  and  indistinct;  the  pulse  is  small 
and  ranges  from  110  to  140  per  minute.  The  tongue  is  dry  and 
fissured,  and  is  protruded  with  difficulty.  Swallowing  becomes 
difficult  on  account  of  dryness  of  the  pharynx;  and  sordes  col- 
lect upon  the  teeth  and  lips.  The  urine  becomes  scanty  and  high 
colored,  and  either  collects  in  the  bladder  or  dribbles  away. 

As  the  disease  progresses,  if  the  case  is  tending  towards  a 
fatal  termination,  the  stupor  deepens,  the  coma  becomes  more 
and  more  profound,  and  the  patient  lies  on  the  back  utterly  in- 
different to  everything  going  on  around  him.  The  tongue  can  no 
longer  be  prot^-uded  from  the  mouth,  the  hands  tremble,  the  ex- 
tremities are  cold,  and  the  muscular  prostration  becomes  extreme. 
The  pulse  rises  to  140  or  150  per  minute,  and  is  small  and  weak  ^ 
at  times  it  becomes  irregular.  The  temperature  which  has  re- 
mained with  but  slight  morning  and  evening  variation  at  105° 
Fahr.,  may  rise  to  107°  Fahr.  or  108°  Fahr.  before  death. 

When  a  fatal  termination  takes  place,  which  is  possible  as 
early  as  the  fifth  day,  or  before  the  end  of  the  first  week,  but 
mostly  between  the  tej  th  and  seventeenth  days,  the  mode  of  death 
is  by  coma,  by  asphyxia,  or  by  heart  failure. 

In  cases  that  tend  towards  a  favorable  termination  there  oc- 
curs, usually  about  the  fourteenth  day,  sometimes  as  early  as  the 
tenth  day,  a  sudden  amelioration  of  all  the  symptoms,  associated 
with  a  critical  defervescence.  The  pulse  and  temperature  sud- 
denly fall,  and  reach  the  normal  or  fall  slightly  below  it,  in  from 
one  to  two  days.     The  stupor  and  coma  rapidly  disappear,  and 


:Aus,..' 


iimmi^i  ■ 


(,'»sr*!^ 


CLINICAL   HIHTOBY. 


270 


fill  nomn  is  n  stnto 
|i  wlucJi  the  piitient 
ith  j^roat  mental  iic- 
|of  iictivo  l»rain  frfi- 
[iiigthia  period.    If 
merges  with  a  (Uh- 
at  passed  before  his 
kco  appears  ilushed, 
ihisky  pallor  about 
bs  and  back  are  no 
things  occur.     The 
is  a  dry,  annoying 
he  breath  and  cuta- 
moim'.Mkc  "  odor. 
it;  the  pulse  is  small 
tongue  is  dry  and 
Iwallowing  becomes 
IX ;  and  sordes  col- 
mes  scanty  and  high 
dribbles  away, 
tending  towards  a 
coma  becomes  more 
the  back  utterly  in- 
The  tongue  can  no 
ads  tremble,  the  ex- 
3n  becomes  extreme, 
i  is  small  and  weak; 
iture  which  has  re- 
ig  variation  at  105° 
before  death, 
hich  is  possible  ns 
the  first  week,  but 
s,  the  mode  of  death 

•mination  there  oo- 
times  ns  early  as  the 
^mptoms,  associated 
id  temperature  sud- 
tly  below  it,  in  from 
idly  disappear,  and 


after  a  prt)l  tnged  and  refreshing  sleep,  the  patient  awakes  to 
conscioiiHiK'ss  as  from  along  and  oppressive  dream.  The  iiiiue 
becomes  increased  in  tjuantity,  and  there  is  a  copious  deixjsit  <if 
unites.  Tin?  eruption  fades  and  slowly  disappears.  The  tongue 
cleans  and  becomes  moist  at  the  edges.  The  appetite  improves, 
the  strength  begins  to  return,  ami  the  patient  enters  \\\Hm  a  rapi(l 
convalt'strence.  Tho  hair  frequently  falls  otV  as  recovery  takes 
place.  Deafness  and  lack  of  mental  vigor  which  are  apt  to  lon- 
tinue  far  into  convalescence,  gradually  disappear. 

Attorl ivr  cases  of  iypliiia  presenting  nil  the  characteristics  of 
the  initial  stage  of  the  disease,  occasion  .lly  appear  during  the 
prevalence  of  typhus  epidemics.  Usually  there  in  no  delirium, 
and  at  the  end  of  the  second,  third  or  fourth  day,  a  critical  def- 
ervescence occurs,  accompanied  by  sweating  and  diarrhea. 

True  relapses  are  rare. 

Complications. — The  complications  of  typhus  fever  like  those 
of  typhoid  fever  ,>re  numerous  and  importniit,  and  an  not  un- 
frequently  the  oaus»>  of  death.  They  vary  in  different  epidemics; 
in  some  they  are  either  cardiac  or  pulmonai.  ;  in  others  they  are 
all  cerebral. 

The  pulmonary  complications  of  typhus,  among  which  may  be 
mentioned,  laryngitis,  bronchitis, lobular  pneumonia,  pulmonary 
gangrene  and  phthisis,  always  approach  insidiously.  Hurried 
resi)iration  and  lividity  of  the  face  are  not  uncommon  danger 
signals.  In  all  cases  you  will  do  well  to  institute  daily  physical 
ex[)loration  of  the  chest. 

L((rynyitis  may  occur  as  an  occasional  complication.  It  usu- 
ally appears  as  an  acute  oedema  glottidis,  although  at  times  it  is 
croupous  in  character.  Its  advent,  which  is  always  insidious, 
should  be  anticipated  whenever  there  is  great  swelling  of  the 
glands  of  the  neck  or  extensive  tumefaction  of  the  mucous  mem- 
brane of  the  pharynx. 

BronchUis  may  occur  at  any  period  of  the  fever.  It  is  devoid 
of  danger  so  long  as  it  is  confined  to  the  larger  bronchial  tubes. 
But  when  it  becomes  diffuse  and  extends  into  the  smaller  tubes, 
it  may  lead  to  atelectasis  and  secondary  lobular  pneumonia,  and 
so  diminish  the  breathing  capacity  as  to  cause  death. 

Lobular  jyneumonia. — The  pneumonia  of  typhus  is  lobular  in 
character.  It  is  frequently  preceded  by  bronchitis  and  displays 
a  tendency  to  terminate  in  abscess  or  pulmonary  gangrene.     It 


mttimd 


StiS.-^'^ 


•;. 


^ 


i 


280 


LIX1TU11E8  ON   Ki-VERS. 


in  iimiuft>ritt!il  by  tlie  UMual  uigUH,  (IuHiichh  coufiiKul  to  one  lung 
(iiHUii'.ly  tli(^  upper  part),  broucliinl  roHpirntitin  nnd  rusty  Hputn. 

Pnliiitmai'i/  (junyrrno  iH  nn^^cctM'unln\,  but  generally  fatal  com- 
plication. ItH  Higns  are,-  dullnoBH  on  p-^roussion,  with  coarse 
nmcous  rales,  grt  inish  or  brownish  and  horribly  fcntid  expector- 
ation, vapid  and  oppressed  breathing,  pM ) lor  and  great  prostra- 
tion. J'urnlcnt  and  serous  pleuritic  offuBi>>ns  tKcasionally  occur, 
and  Bomotinies  ])hthisis  supervenes  during  convalescence. 

McniiufifiH  is  the  principal  ci  "bral  c«)inplicHtion.  It  is  most 
rnblr",  U)  occur  during  the  second  week  of  the  fever,  and  is  oftener 
mt'i  wii)i  in  children  than  in  .ilults.  Its  ])reHeiice  is  manifested 
by  intense  bi-lateral  headaclie,  with  restlessness  which  shows 
itself  by  constant  attempts  to  get  out  of  bed,  redness  of  the  face 
and  eyes,  intense  sensitiveness  to  ligl)^  and  sound,  contracted 
pupils,  with  contractions  of  the  Hexor  iuasclesof  the  arm  and 
leg,  followed  by  somnolence  lapsing  ii  :i  coma.  Dilatation  of 
the  jjupils  with  slow  stertorous  breathing,  and  an  intermitting 
almost  I iJiperceptiblt  ^  ulse,  immediately  precede  death. 

Feebi-mss  of  iiitellei )  and  attacks  of  mania,  show  themselves 
in  a  small  proportion  oi;  cases  during  convalescence.  They  are 
commonly  transient,  lasting  only  a  few  days  or  weeks. 

Paraliisis  may  occur  as  a  sequel  of  typhus,  but  usually  ter- 
minates within  a  limited  period  after  recover)-.  Hardness  of 
hearing,  which  is  a  frequent  attendant  during  the  course  of  the 
fever,  commonly  disappears  as  convalescence  becomes  estab- 
lished. Occasionally  permanent  deafness  occurs  as  a  result  of 
inflammation  of  the  external  or  of  the  middle  ear.  Transient 
dimness  of  vision  has  been  observed'  in  some  epidemics,  and 
perforating  ulceration  of  both  corneuo  occasionally  occurs  as  a 
result  of  prolonged  exposure  of  the  eyeballs. 

Croupous  nephritis  occasionally  occurs  during  the  course  of 
typhus.  Its  occurrence  is  indicated  by  urinary  suppression,  and 
by  the  presence  of  albumen  and  of  hyaline,  and  blood  casts  in 
the  urine. 

Olandular  swellings  occasionally  occur  as  complications,  and 
are,  as  a  rule,  most  frequently  observed  in  adults.  They  may 
appear  either  in  the  early  days  of  the  fever  or  immediately  after 
the  crisis.  They  are  most  apt  to  involve  the  parotid  and  the 
sub-maxillary  glands;  less  frequently  the  mammje  and  the  axil- 
.lary  and  inguinal  glands  become  implicated.      The  swellings, 


01 


mum 


im 


)ufinr>(l  to  one  lung 
n  Riul  iniHty  Bpiita. 
oiierally  fatal  coui- 
Bsion,  with  coarse 
bly  fcatid  expector- 

aud  great  prostra- 
occasionally  occur, 
nvalescencG. 
icntion.  It  Ih  inoBt 
ever,  ami  is  ofteiier 
lence  is  luauifested 
mess  which  shows 
redness  of  the  face 

sound,  contracted 
es  of  the  arm  and 
)ma.  Dihitation  of 
nd  an  intermitting 
iede  death. 
a,  show  themselves 
escence.  They  are 
or  weeks. 

IS,  but  usually  ter- 
erj'.  Hardness  of 
g  the  course  of  the 
ce  becomes  estab- 
jcurs  as  a  result  of 
lie  ear.  Transient 
me  epidemics,  and 
sionally  occurs  as  a 

ring  the  course  of 
ry  suppression,  and 
,  and  blood  casts  in 


W- 


complications,  and 
adults.  They  may 
ir  immediately  after 
he  parotid  and  the 
Qimte  and  the  ax.il- 
d.      The  swellings, 


■«BHB«B 


Si>. 


'/ 


^ 


L. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


I^|2j8     |2.5 

■^  Kii   |2.2 


HJil 


1-25   |l.4    |||.6 

■• 6"     

► 

•• 


Photographic 

Sdences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14S80 

(716)  872-4503 


"■"'^j9*S5W-;?-JWS!!95JjEi^W^!(»^^ 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICIVIH 
Collection  de 
microfiches. 


jfc«* 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


ANALYSIS   OF   CHAUT. 

usually  form  rapidly,  and  speedily  tend  tos  'opuration;  occasion- 
ally resolution  occurs.  "When  imroUtis  occurs,  it  is  not  infre- 
quently associated  with  facial  erysipelas  or  with  extensive 
inflammatory  oedema  of  the  neck,  and  oedema  of  the  glottis. 

Sub-cuianeoHs  extravasations  of  blood  are  not  uncommon 
in  some  epidemics.  While  hemorrhages  from  the  nose,  bowels, 
kidneys  and  uterus,  have  been  occasionally  observed. 

Boils,  and  diffuse  injlammation  of  the  sub-cutaneous  tissues 
resulting  in  purulent  infiltration,  are  not  infrequently  met  with 
in  some  epidemics.  Wounds  and  ulcerated  surfaces,  and  even 
parts  not  subjected  to  pressure,  may  at  times,  in  consequence  of 
arterial  thrombosis,  become  gangrenous. 

Pyaemia -wiih  purulent  deposit  in  the  smaller  joints  is  an  occa- 
sional though  rare  occurrence.  It  commonly  appears  about  the 
time  of  the  crisis  and  is  manifested  by  severe  chills,  rapid  and 
feeble  pulse,  jaundice,  delirium,  great  prostration  and  redness, 
tenderness  and  swelling  of  the  joints. 

Bed-sores,  which  are  common  and  troublesome  complications 
of  typhoid  fever,  are  rarely  present  in  ordinary  typhus  fever. 
In  protracted  cases,  however,  they  are  apt  to  appear,  especially 
over  the  sacrum  and  trochanters,  and  may,  if  extensive,  lead  to 
exhaustion  and  death. 

Duration. — The  average  duration  of  typhus  fever  is  from 
thirteen  to  fifteen  days.  It  is  shorter  in  childhood  and  youth, 
than  in  middle  and  advanced  life.  Mild  cases  may  terminate  at 
the  end  of  the  first  week  or  at  the  beginning  of  the  second  week. 
Uncomplicated  cases  rarely  last  longer  than  twenty  days. 

Complications  may  protract  the  course  of  the  disease  to  four, 
five  or  even  six  weeks.  The  day  of  crisis  is  usually  between  the 
tenth  and  sixteenth  days.  The  mean  duration  of  the  fever,  which 
is  fourteen  days,  is  usually  longer  at  the  beginning  than  at  the 
close  of  an  epidemic. 

ANALYSIS   OF  CHART. 

The  Nervous  Hyntem.— Headache  is  one  of  the  earliest  and 
most  constant  symptoms  of  typhus.  It  is  usually  present  at  the 
onset  of  the  attack,  and  is  frequently  associated  with  vertigo. 
It  is  dull  or  heavy  in  character,  and  is  located  mainly  in  the  fore- 
head and  temples;  exceptionally  it  is  confined  to  the  vertex  or 
occiput.     It  remains,  as  a  rule,  persistent  during  the  first  week 


(I 


mm 


tammsn'' 


r 


ww-^  ww-tp  >  I  m  >     '  ■  ■  ^  .""Lu^*  'j'-H-cifst:'-;  ■  ''■'^'", ' 


282 


LECTURES  ON  FEVERS. 

CHART  Xll.—Tifphns  Fever. 


%. 


NiUiuc: 

Kpi'leinic.                                 lliKlily  Contii(rioiis. 

[nitial  Hympioiii: 

A  short,  shiup,  sudiim  ehil' 

Stiiges: 

First  Week. 

Second  Week. 

Third  Week. 

Face: 

(•'lushed.    Mahotfany 
colored  checks 

L)ull,  heavy  express-, 

lull. 

Jountenance  natural. 

Eyes:             Wntury  and  Injoctcd- 

Pupils  colli lacted. 

Normal. 

E«r»: 

Noises  In  the  ears. 

1 
Deafness. 

Deafness   disappears 

Kprtu  KMi-  oil  tl  Kt  day.  Slltflit  remission  from 

Tt-mpernture:         miixiniuiii    <in    ;t<l     "tti  to  Hlth<iiiy.    Crisl? 

or4lli<ltiy.             Iioin  Htli  to  14th  diiy 

3udden  defervescence 

Pulse: 

100  to  Via.    First  full. 
then  soft. 

imtol4n.    WenkhcHit 
impulse    after    Uth 
day. 

Declines  rapidly. 

Hespiratlon,  etc: 

.>(!  (o  ;«)  piT   mitiiitc. 
ciilarrhrtl  symp- 
toms. 

Ml  to  40  or  .10  per  min- 
ute.   Uronchitls. 

Ileturns  to  normal. 

(jHtiiiieous 
Surface: 

Dry  skin.      Pungent 
heat. 

"Mouse-like"  odor. 

Uriiii-like   des<iuama- 
tion.        Temporary 
los-!  of  hair. 

Eruption: 

"Mulberry    rush"   on 
nth  day.     i-»n  alido- 
men  and  extremities 

Each  spot  lasts  until 
rceovery  or  death. 
PctechiiB. 

Oraduaiiy  disappears. 

Nervous  System: 

Frontal      henda<-hc. 
Wiikefulness.    I'liiii 
in  the  thiifhs.   Pros- 
trntiim. 

Deilrinin.     Deafness. 
(;oma  vigil. 

Muscular  pains.  Kest- 
ful  sleep. 

Tongue: 

First   whit'',    thou 
brownish-yellow. 
'Ihlist. 

Dry,    dark.    Hssured 
Tremulous. 

Clean  and  moist. 

Intestinal  Canal ; 

Nausea.  Constipation 

Constipation       Occa- 
sionally slight  diar- 
rhtea. 

Constipation. 

Urine: 

Diminished.  Highcol 
orod.        Excess     oi 
urea. 

.Transient  aUuimluu- 
rla.    Uetention. 

Palo.    Increased. 

Complications ; 

(iliindular  swellings.    Cerebral  and  pulmonary  difflcuitles. 

Duration : 

Average  duration  13  or  It  days. 

Mortality: 

Varies  from  0  to  20  per  cent. 

Lesions: 

No  constant  post  mortem  appearances. 

Incubation: 

Two  weeks. 

Coatii-lous  Uls- 
tanee: 

About  two  feet. 

Uelapses: 

Hela 

pses  ore  extremely  ra 
leeurs  only  once  in  a  1 

re. 

1      Kecurrence: 

Typhus 

ifetiino. 

i 


i^iixis. 


hlnl  Week. 


L'iMiiice  naturul 


Niiiinal. 


ess   illsHppears 


ndffcrvpsccnce 


lines  rnplfily. 


rna  to  normal. 


like  (letxummii- 
I.  'I'l'iiiporary 
of  hair.     


lally  disappears 


iilar  pains.  Kest- 

slicp. 


m  und  moist. 


onstipatlon. 


lo.    Increased. 


dllBculties. 


ANALYSIS   OF  CHAllT. 

,,  t.n  anyK,  after  which  it  gradually  disappears  upon  the  advent 
of  delirium.  ,  „,u»p(vrs  usually  about 

At  wbatovov  „eri«Ut  »  ''«*1>-:1.  '  ^  „\  X"  (  tl.e  delirium 
vanes  greatly.     It  is  generHu:y  i       '    ^  ^j    -^  j^  j^gtive  and 

,„,Uy    and  -rW-  *a  o!  deh  ^  ^  _^^  _^  __^_^^^  j_^^^^^^, 

"""tt  tCinteC"  '  3.  .nd  in  yonng  person,  o£  .>ct,ye 

e„„es  continuouB  and  « t  »n  -- »  __>  '^^^^  ,.^^,,,i„g  ,,„„. 

J^„c(„r«ai  7'  f  *  --I'^t'^rr  At  times  there  i»  diowsines, 

^Te  d^Se    wlt^  iri  wakefulness  and  delirium  at 

'"  »  Not  wluontly  the  patient  lies  for  hours,  pale  and  ex- 
mght.     JNot  inirequt.uiijr         i  j^  ^^j^j 

pressionless,  and  almost  l-l^^^.^^'. ^^'^^ '^^^^^^f  "  ..rently  un- 
le  skin  bathed  in  a  cold  Pe-P-^-^;  J^^^^^^^  ^^.J  and 
conscious,  he  is  evidently  awake,  but  absolute  >  ^^  .^ 

insensible  to  everything  f  f -^^ved  C^^^^^ 

condition,  which  IS  almost  a^^^^^^^^^^^^  ^^^^  ^pp^i,,. 

the  by  no  ^^'^-^^^^S^^f;^;^^^^^^^^^^  ad;anced  stage  of  the 

At  any  time,  and  "^^^V^P™ 

disease,  the  occurrence  of  ^^y/™' ^^^^^^      symptoms. 

your  utterances  guarded  as  to  ««^"^8  ne^^^^  ^^^^_ 

As  the  fever  progresses  t^^^^f  ^^«  ^  ^Xn^^^^^^^^^ 

siness  deepens  ^y  ^-P-^^^^^^^^^  svJddenly. 

theninto  profound  coma.     ^<^^J'^2  albuminous  urine. 

and  is  then  apt  to  be  associated  ^^"^  ^^f^^^^^^^^^^^^  ,,,i  ,y^ptom 
LO.S8  of  muscidar  strength  is  a  PJ^^;^^^^^^^^^  J^pVed  to 
of  typhus.  In  the  majority  o  ;--  *  -/  ^^^^^^  V^^  fi  J  day  of 
take  to  the  bed,  on  accoun  ^^^.^^f^'^^^^^^^  ^o  extreme, 
the  fever.     Not  infrequent  y  the  debd^^y^^^^^^^^^  ^^^ 

that  the  patient  is  unable  to  rise   ^^^Tse  advances,  and  ia 

prostration  generally  increases  ^^^^^^^^^    r^^^,  ^,,^on  o£ 
often  complete  about  the  ninth  or  twelfth  day.  P 


MM 


r| 


/ 


284 


LECTURES  ON   FEVERS. 


the  patient  in  bed,  is  usually  on  the  back;  with  the  increasing 
prostration  there  is  almost  always  a  tendency  to  sliding  down 
in  bed. 

Along  with  the  marked  and  steadily  increasing  debility,  there 
is  apt  to  be  paralysis  of  the  muscles  of  the  rectum  and  bladder. 
The  urine  and  fsoces  may  be  passed  involuntarily,  in  consequence 
of  paralysis  of  the  anal  and  vesical  sphincters.  Sometimes  the 
urine  is  retained,  and  there  is  over-distension  of  the  bladder  in 
consequence  of  paralysis  of  the  muscular  coat.  Tremulousness 
aflfecting  more  especially  the  hands  and  tongue,  is  almost  con- 
stantly observed  in  severe  cases.  General  muscular  tremors 
occur  in  the  aged  and  infirm,  and  in  those  who  have  been  addicted 
to  the  too  free  use  of  intoxicating  drinks.  Ataxic  symptoms, 
such  as  subsultus  tendinum,  spasmodic  twitchings  of  the  facial 
muscles,  carphologia,  and  picking  at  the  bed-clothes,  are  present 
to  a  greater  or  less  degree  in  all  severe  cases.  Nystagmus  and 
obstinate  hiccough  occasionally  occur.  Tense  contractions  of 
the  flexor  muscles  of  the  forearm,  thighs  and  legs,  are  very  rare, 
and  occur  only  in  grave  cases. 

General  convulsimis  are  not  often  met  with;  but  if  they  do 
appear,  which  is  generally  towards  the  end  of  the  second  week, 
life  is  seldom  prolonged  beyond  three  or  four  days.  They  are 
usually  preceded  by  a  tendency  to  stupor  or  to  coma,  and  by  a 
marked  diminution  in  the  quantity  of  urine,  and  are,  as  a  rule, 
caused  by  uraemia. 

The  Special  Senses.— In  the  early  days  of  the  fever,  (he  eyes 
are  watery,  the  conjunctivie  are  deeply  injected,  and  the  pupils 
are  contraded.  Hardness  of  hearing,  preceded  by  ringing  noises 
in  the  ears,  is  very  common  after  the  middle  of  the  first  week, 
and  frequently  extends  into  convalescence.  Cutaneous  hyperoB- 
sthesia  is  a  not  uncommon  symptom  during  the  first  week. 

The  Temperature.— The  temperature  range  in  typhus  fever 
(fig.  15),  is  shorter  and  rises  more  rapidly  to  the  maximum,  than 
-does  that  of  typhoid  fever.  The  fever  increases  rapidly  from 
the  onset  of  the  disease,  and  the  temperature  observes  very 
nearly  the  following  formula  of  ascent: 

It  reaches  103°  Fahr.  or  105°  Fahr.  on  the  first  evening;  on 
the  next  morning  it  recedes  to  between  98J°  Fahr.  and  103° 
Fahr. ;  on  the  eecond  evening  it  rises  up  to  or  above  104.5*  Fahr. ; 


TEMl'EllATUKE   IIANOE. 


285 


the  iiicrensing 
sliding  down 

(lobility,  there 

m  nnd  bladder. 

ill  consequence 

Sometimes  the 

the  bladder  in 

Trennilousness 

is  almost  con- 

scttlar  tremors 

e  been  addicted 

ixic   symptoms, 

gs  of  the  facial 

lies,  are  present 

Ifystagmus  and 

contractions  of 

s,  are  very  rare, 

but  if  they  do 
le  second  week, 
lays.  They  are 
coma,  and  by  a 
d  are,  as  a  rule, 

i  fever,  (he  eyes 
and  the  pupils 
y  ringing  noises 
f  the  first  week, 
aneous  liyperjB- 
Brst  week. 

in  typhus  fever 
maximum,  than 
Bs  rapidly  from 
J  observes  veiy 

rst  evening;  on 
Fahr.  and  103° 
ive  104.5^  Fahr.; 


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280 


LECTUnES  ON   FEVERS). 


on  the  tlurd  evening  it  often  renclies  105"  Fahr.  or  106.J°  Fahr. 
exceptionally  it  does  not  rise  above  102'^  Fahr. ;  and  on  the  fourtli 
evening  it  is  rarely  under  105.8°  Fahr.  and  not  infrequently  it 
attains  107"  Fuhr.     In  children  it  may  not  at  any  time  exceed 
103°  Fahr. 

In  mild  or  moderate  e<ines,  the  maximum  is  reached  on  the 
fourth  day,  and  at  the  close  of  the  week  there  is  a  slight  decrease 
of  temperature.  On  the  seventh  or  eighth  day,  there  is  a  more 
marked  remission,  followed  on  the  ninth  day,  seldom  later,  by  a 
rise  of  from  0.5°  Fahr.  to  3.5°  Fahr.,  which  lasts  from  one  to 
three  days,  and  then  slowly  subsides.  A  third  remission,  occu- 
pying a  half  day  or  two  mornings,  occurs  about  the  twelfth  day, 
and  is  followed  by  a  third  brief  rise,  which  terminates  in  defer- 
vescence. 

In  severe  and  neylecied  cases,  the  temperature  continues  to 
rise  through  the  first  week  until  it  reaches  106°  Fahr.  or  107° 
Fahr.  It  remains  persistent  at  104°  Fahr.  in  the  morning,  and 
at  105°  Fahr.  or  106°  Fahr.'  in  the  evening,  through  the  whole  or 
a  i)nrt  of  the  second  week.  Gases  which  tend  to  recovery  show 
a  slight  declination  towards  the  end  of  the  second  week,  and  yet 
the  high  temperature  continues  during  the  third  week.  In  these 
severe  forms,  the  temperature  range  differs  from  that  of  typhoid 
fever  in  that  the  daily  maxima  ra'e  higher,  and  there  is  less  tend- 
ency to  remissions. 

The  stage  of  defervescence  in  typhus  occupies  from  twelve 
hours  to  two  or  three  days,  and  is  usually  very  characteristic. 
It  is  generally  preceded  by  a  short  critical  perturbation,  a  rise 
of  from  0.2°  Fahr.  to  3.5°  Fahr.  above  the  preceding  evening, 
and  follows  it  in  a  precipitous  or  progressive  descent.  Occasion- 
ally there  is  no  cliange  in  the  temperature  before  the  time  of 
crisis,  and  when  this  is  the  case,  the  defervescence  is  very  grad- 
ual. The  critical  defervescence  usually  appears  between  the 
thirteenth  and  seventeenth  days,  and  the  temperature  sometimes 
falls  in  a  single  night  from  104°  Fahr.  or  higher  to  the  normal. 
Recovery  genei'ally  takes  place  after  the  crisis.  During  the  first 
week  of  convalescence,  the  temperature  often  remains  below  the 
normal,  especially  in  the  morning. 

A  very  higli  range  of  temperature  during  the  first  week  indi- 
cates severe  cerebral  symptoms  during  the  second  week. 


J 


or  106.0°  Fahr. 
lid  oil  the  fourth 
t  infrequently  it 
any  time  exceed 

}  reached  on  the 
a  slight  decrease 
,  there  is  a  more 
eldom  later,  by  a 
sts  from  one  to 
remission,  occu- 
;  the  twelfth  day, 
ninates  in  defer- 

;ure  continues  to 
6"  Fahr.  or  107° 
he  morning,  and 
ugh  the  whole  or 
to  recovery  show 
nd  week,  and  yet 
I  week.  In  these 
a  that  of  typhoid 
liere  is  less  tend- 

ies  from  twelve 
I'y  characteristic, 
rturbation,  a  rise 
3ceding  evening, 
scent.  Occasion- 
Eore  the  time  of 
nee  is  very  grad- 
ars  between  the 
rature  sometimes 
Br  to  the  normal. 
During  the  first 
>mains  below  the 

?  first  week  indi- 
nd  week. 


THE  ERUPTION. 


287 


The  absence  of  a  slighfiemission  about  the  seventh  or  eightli 
day  is  an  unfavorable  omen. 

A  sudden  rise  during  the  first  week  indicates  the  occurrence 

of  ccunplications. 

Fatal  cases  announce  themsolves  at  the  outset,  by  an  enormous 
height  of  temperature,  106 '  Fahr.,  or  more. 

Just  before  death  and  in  the  death  agony,  the  temperature 
rises  from  2°  Fahr.  to  6.5°  Fahr. 

The  Pulse.— In  the  beginning  of  an  attack  the  pulse  is  usu- 
ally full,  soft  and  compressible.     As  the  disease  progresses  it 
diminishes  in  force  and  rises  in  frequency.     It  ranges  from  110 
to  130  beats  per  minute.     On  the  third  day,  in  mild  cases,  it  sel- 
dom exceeds  100,  while  in  severe  cases  it  may  reach  120  or  l.iU. 
In  unfavorable  cases  it  may  run  up  to  140  or  even  150  per  min- 
ute    A  pulse  which  remains  for  three  consecutive  days,  above 
120  per  minute,  is  a  bad  omen.    During  the  first  week,  the  pulse- 
rate  and  the  temperature-range,  usually  correspond,  but  after 
this  time  the  parallelism  ceases.     During  the  second  week,  es- 
pecially if  the  debility  is  very  great,  the  pulse  may  become  more 
rapid  as  the  temperature  falls;  or  the  pulse  may  at  other  times 
diminish  in  frequency,  and  yet  the  temperature  rise.     A  rapid 
fall  in  the  pulse  rate  during  defervescence  is  usually  a  favorable 
indication.     A  decided  rise  after  it  has  fallen  is  frequently  indi- 
cative of  pulmonary  complications. 

The  heart  impulse  is  almost  invariably  enfeebled,  after  the 
fifth  or  sixth  day  of  the  fever,  and  the  cardiac  first  sound  is  oc 
casionally  replaced  by  a  soft  systolic  murmur.  As  convalescence 
becomes  established  both  the  impulse  and  the  first  sound  slowly 
return  to  normal. 

The  Eruption.— The  eruption  of  typhus  fever,  which  is  very 
rarely  absent,  appears,  as  a  rule,  on  the  fourth  or  fifth  day.  It 
is  preceded  and  accompanied  by  an  erythematous  redness  of  the 
whole  surface,  and  is  first  seen  upon  the  sides  of  the  chest  and 
abdomen.  It  consists  of  a  mottling  or  marbling  of  the  skin, 
described  as  the  suh-cuUcular  rash,  and  of  pale,  dirty  pink,  or 
florid  spots,  slightly  raised  above  the  surface,  disappearing  on 
pressure,  and  preeenting  by  their  grouping,  a  close  resemblance 
to  measles.  After  iwo  or  three  days  they  are  no  longer  elevated 
and  distinct,  but  frequently  appear  as  illy-defined  rust-colored 


WbaiMHHNMM 


r 


288 


LECTURES  ON  FEVERS. 


stains,  which  are  hut  sliglitly  influPiiceil  hy  pressure.  Tlie  Huh- 
cuticuhir  mottlings  grnduiilly  (liHnppoar  ns'the  spots  grow  ilnrker. 
The  Ifittftr  are  generally  darker  and  more  distinct  on  the  depend- 
ent portions  of  the  body.  The  extent  and  lividity  of  the  eruption 
are,  usually,  proportionate  to  the  severity  of  the  attack. 

During  the  second  week,  the  centers  of  some  of  the  pigmented 
spots,  become  the  sites  of  minute  extravasations  of  blood.  In 
some  cases  true  petechiie  appear;  they  are,  however,  seldom 
present  l)efore  the  last  stages.  After  death  the  petechia)  and  the 
rusty  stains  remain  persistent,  but  the  pinkish  or  florid  spots 
usually  disappear. 

The  duration  of  the  rash,  which  generally  disappears  with 
defervescence,  is  from  eight  to  twelve  days. 

Minute  transparent  vesicles,  called  sudamina,  have  been  ob- 
served in  a  limited  number  of  cases,  at  a  late  period  of  the  dis- 
ease. Urticaria,  herpes  and  erysipelas,  exceptionally  occur. 
Changes  in  the  nails,  as  shown  by  white  bands  and  furrows,  in- 
dicating arrest  of  nutrition  during  the  fever,  not  infrequently 
take  place.  Slight,  bran-like  desquamation,  proceeding  from 
above  downward,  occasionally  occurs,  during  convalescence. 

Emaciation  is  seldom  marked,  and  is  rarely  present  before 
the  third  week. 

The  ammoniacal  or  "mouse-like"  odor,  which  emanates  from 
typhus  patients  is  said  to  be  characteristic. 

The  Respiratory  System.— During  the  first  week  the  respira- 
tions rarely  exceed  twenty  or  thirty  per  minute.  But  during  the 
second  week,  with  the  advent  of  delirium,  they  become  hurried 
and  range  from  forty  to  fifty  per  minute.  In  grave  cases,  when 
the  prostration  is  extreme,  and  the  stupor  becomes  profound, 
they  are  irregular  and  sometimes  fall  to  eight  or  ten  per  minute! 

Nasal  and  bronchial  catarrh  attended  with  slight  cough,  ia 
usually  present  during  the  first  week.  Diffuse  bronchitis,  hy- 
postatic congestion  of  the  lungs,  or  lobular  pneumonia  may 
appear  during  the  second  week.  Diphtheritic  croup  has  been 
observed  in  some  epidemics. 

The  Digestive  System.-The  changes  in  the  digestive  tract 
are  mainly  functional  in  character.  Nausea  and  vomiUng  are 
rare.  Vomiting  occurs  as  an  early  symptom,  principally  in  dys- 
peptic individuals;  occurring  after  the  first  week,  it  is  occasion- 
ally the  precursor  of  ursemic  convulsions  and  coma. 


MORBID  ANATOMY. 


2R9 


[)re88ure.  Tlie  sub- 
e  spots  grow  ilnrker. 
tinct  on  the  depeiul- 
idityof  t lie  eruption 
the  attnck. 
ie  of  the  pigmented 
tions  of  blood.  In 
},  however,  sfldom 
le  petechifc  and  the 
kish  or  florid  spots 

!ly  disappears  with 

lina,  have  been  ob- 
)  period  of  the  dis- 
xceptionally  occur, 
ds  and  furrows,  in- 
r,  not  infrequently 
I,  proceeding  from 
convalescence, 
rely  present  before 

lich  emanates  from 

at  week  the  respira- 
te.  But  during  the 
ey  become  hurried, 

grave  cases,  when 
aecomes  profound^ 

or  ten  per  minute, 
h  slight  cough,  is 
ise  bronchitis,  hy- 
r  pneumonia  may 
ic  croup  has  been 

the  digestive  tract 
1  and  vomiting  are 
principally  in  dys- 
eek,  it  is  occasion- 
coma. 


At  first  thp>  lotiffiif  is  covered  with  a  wliitinh  or  yollowlHli-whito 
fur.  TowimlH  tlio  (Mid  of  tho  fii-Kt  week,  it  bucuiiics  dry  mul 
l)r()\vn  al^d  is  protruded  troinuli  )UHly.  N(  it  unf  nMineiitly,  in  Hovore 
c-iirtert,  it  becfunes  dry  and  crustt'd,  and  iw  tirinly  rotraotod  into  a 
globular  mass.  In  grave  cases,  about  tlie  b(>giniiing  of  the  sec- 
ond week,  Hordos  coUfct  upon  tho  gums,  teeth  and  lips. 

Thirst  and  (luorcria  iiro  couHtant  8yin])toinH.  Tlui  fornior  is 
moHt  marked  during  tho  first  but  diminirilies  during  tiio  second 
week.  Tho  latter  is  complete  throughout  the  attack,  but  disap- 
pears, often  suddenly,  during  the  sleep  that  marks  the  crisis. 

Constipation  is  the  rule,  A  mild,  dark,  greonish-brown  diar- 
rhea sometimes  occurs  at  the  period  of  critical  defervescence. 
Involuntary  discharges  occur  only  in  severe  cases,  and  generally 
upon  the  approach  of  death.  Acute  enlargement  of  tlie  spleen 
is  frequently  present. 

The  Urine. — At  first  the  urine  is  diminished  in  quantity,  and 
is  high-colored  and  of  high  specific  gravity.  It  is  acid  in  reac- 
tion, and  contains  more  urea  and  less  chlorides.  A  small  amount 
of  albumen  is  frequently  present  early  in  the  attack,  and  in  se- 
vere cases  it  may  be  copious  and  persistent.  Renal  epithelium, 
and  epithelial  and  fatty  casts  are  not  uncommon.  Later  in  the 
disease  the  urine  may  become  suppressed,  and  urinary  retention 
may  render  the  use  of  the  catheter  necessary. 

As  convalescence  approaches  it  becomes  pale  and  increased  in 
quantity.  The  chlorides  reappear,  the  amount  of  urea  lessens, 
and  the  albumen  gradually  disappears. 

Morbid  Anatomy. — Typhus  fever  has  no  known  special  and 
characteristic  lesion.  Morbid  appearances  in  different  organs 
are  frequently  found  after  death,  but  they  are  due  to  the  pro- 
longed, intense  pyrexia,  or  to  complications. 

The  body  is  seldom  very  much  emaciated,  unless  death  has 
taken  place  after  the  second  week.  Cadaveric  rigidity  is  usually 
of  short  duration;  and  decomposition  takes  place  rapidly. 

The  blood  is  darker  than  normal.  When  drawn  from  the  body 
it  coagulates  imperfectly  and  rapidly  undergoes  ammoniacal  de> 
composition.  The  fibrin  is  diminished,  while  urea  and  ammonia 
are  in  excess.  The  red  globules  become  diminished  in  quantity, 
and  when  examined  under  the  microscope,  many  of  them  pre- 


mmsmmMm 


■fHHH 


290 


LECrUBEB  ON  FEVERS. 


BPiit  serrated  odgos,  nnd  Bome  are  found  to  have  undergone  de- 
gciiorfttion. 

The  Iwart  undergoes  granuhir  degenerative  change*,  i)ropor- 
tioniito  to  the  intensity  and  duration  of  the  febrile  movement.  It 
in  soft  and  flaccid;  the  muscular  tissue  is  of  a  yellowish-brown 
color,  and  easily  torn.  The  feebleness  of  heart-impulse  is  pro- 
portionate  to  the  degree  of  degeneration  found  after  death. 
Thrombi  are  often  discovered  in  the  superficial  veins  of  the  lower 
limbs.  They  are  usually  formed  by  a  slowing  of  the  general 
circulation,  consequent  upon  the  great  feebleness  of  heart  power, 
and  are  apt  to  cause  swelling  of  one  or  both  extremities. 

The  kidneys  are  commonly  hyperromic,  and  are  apt  to  be  en- 
larged in  consequence  of  a  cloudy  swelling  of  the  epithelium  of 
the  renal  tubes. 

The  liver  and  spleen,  are,  as  a  rule,  enlarged.  The  former  is 
bypenemic  during  the  first,  and  more  or  less  fatty  and  friable 
during  the  second  week.  The  latter  undergoes  softening,  early 
in  the  disease,  even  during  the  first  week,  and  interstitial  extrava- 
sations of  blood,  not  infrequently  occur. 

The  respiralory  trad  exhibits  signs  of  catarrhal  inflammation 
of  the  bronchial  tubes.  Patches  of  atelectasis  are  often  found 
as  a  result  of  capillary  bronchitis.  Evidences  of  hypostatic 
congestion,  of  catarrhal  pneumonia,  of  pulmonary  oedema  or  of 
pulmonary  gangrene,  are  also  frequently  observed. 

The  braiii,  as  a  rule,  presents  some  changes.  The  cerebral 
vessels  will  be  found  to  be  intensely  congested,  or  else  an  abun- 
dant, usually  clear,  fluid  effusion,  varying  in  quantity  from  one 
to  eight  ounces,  will  be  observed  underneath  the  arachnoid  and 
in  the  ventricular  cavities. 

Enlargement  of  the  sub-lingual  and  parotid  glands,  is  a  not 
infrequent  autopsic  phenomenon. 


^^^^^^RIS" 


have  undergone  de- 

vo  chnn(?eS,  jjropor- 
sbrile  movement.  It 
)f  n  yellowish-brown 
lenrt-irapulse  in  pro- 
found after  death, 
lal  veins  of  the  lower 
ving  of  the  general 
mens  of  heart  power, 
extremities, 
mcl  are  apt  to  be  en- 
)f  tlie  epithelium  of 

ged.  The  former  is 
less  fatty  and  friable 
goes  softening,  early 
i  interstitial  extrava- 

tarrhal  inflammation 
tasis  are  often  found 
iences  of  hypostatic 
monary  oedema  or  of 
aserved. 

mges.  The  cerebral 
tted,  or  else  an  abun- 
in  quantity  from  one 
ih  the  arachnoid  and 

'otid  glands,  is  a  not 


LECTURE  XIX. 

Typhus  Fever   (Continued.) 

I  will  direct  your  attention  to-day  to  the  differential  diagnosis 
and  treatment  of  tyi)hu8  fever. 

Differential  Diagnosis.— The  diagnosis  of  this  disease  can- 
not be  definitely  determined  before  the  appearance  of  the  erup- 
tion. During  the  prevalence  of  an  epidemic,  the  sudden  onset 
of  fever,  after  a  short,  sharp,  sudden  chill,  with  a  rapid  rise  in 
temperature,  dull,  heavy,  steadily  increasing  frontal  headache, 
pain  in  the  back  and  limbs,  and  early  and  extreme  prostration 
are  markedly  suggestive  typhus  symptoms.  The  "mulberry 
rash "  on  the  fifth  or  sixth  day,  and  the  critical  defervescence 
about  the  fourteenth  day  are  characteristic. 

The  diseases  with  which  it  is  most  liable  to  be  confounded  are, 
typhoid  fever,  relapsing  fever,  cerebro-spinal  fever,  iitoflsles, 
pneumonia,  acute  Bright's  disease,  deluium  tremens,  remittent 
fever,  pyaemia  and  the  plague. 

The  rules  for  differentiating  typhoid  fever  and  relapsing  fever 
(p.  166),  and  cerehro-sjnnal  fever  (p.  236),  I  have  already  given 
you  in  the  lectures  upon  those  diseases. 

Measles  as  distinguished  from  typhus  fever,  in  children,  is 
characterized  by  the  corjaa  and  cough  of  the  pre-eruptive  stage, 
by  the  intensely  injected  pharyngeal  mucous  membrane,  by  the 
brighter  tint  of  the  eruption,  by  the  presence  of  the  eruption 
upon  the  face,  and  by  the  absence  of  nervous  symptoms  such  as 
delirium,  prostration  and  a  tendency  to  coma. 

Pneumonia,  with  typhoid  symptoms,  is  sometimes  mistaken 
for  typhus  fever.    If  there  is  no  eruption  present,  the  appear- 

(201) 


I 


292 


LECTURES  ON  FEVERS. 


ance  of  the  physical  signs  of  pulmonic  consolidation,  is  sug- 
gestive of  pneumonia;  for  pulmonary  consolidation  as  a  compli- 
cation of  typhus  is  not  developed  until  after  the  sixth  day  of  the 
fever,  at  which  time  the  eruption  is  generally  visible. 

Acute  Brujhf.H  (h'scase,  which  at  times  closely  resembles  ty- 
phus fever,  may  be  diiferentiated  by  the  lower  temperature  range, 
by  the  i)reseuce  of  oedema,  and  by  the  absence  of  the  typhus 
rash. 

Delirium  tremens,  occasionally,  closely  resembles  typhus.  It 
differs  however,  in  that  it  is  generally  marked  by  a  lower  range  of 
temperature — seldom  above  iOO°  Fahr. — and  by  the  absence  of 
eruption.  As  a  rule  it  is  ushered  in  by  insomnia  instead  of  head- 
ache, and  under  circumstances  which  establish  beyond  a  doubt 
the  nature  of  the  attack. 

Remittent  fever,  especially  that  malignant  form  which  prevails 
in  tropical  countries,  is  attended  by  many  symptoms  of  typhus. 
It,  however,  lacks  the  eruption  ot  typhus,  and  is  apt  to  be  asso- 
ciated with  other  malarial  types  of  disease.  It  is  always  attended 
by  a  greater  enlargement  of  the  spleen. 

Pycemia,  septiccumia  and  erysipelas  are  often  attended  by 
many  of  the  ushering-in  symptoms  of  typhus,  and  when  the 
latter  is  epidemic,  it  will  be  frequently  impossible  to  make  a 
differential  diagnosis  until  after  the  time  for  the  typhus  erup- 
tion. 

The  plague  resembles  typhus  in  that  it  is  highly  contagious, 
and  is  attended  with  marked  cerebral  and  petechial  symptoms.  It, 
however,  diffeis  from  it  by  running  a  shorter  course,  and  by  being 
attended  by  nausea,  vomiting  and  swelling  of  the  inguinal  and 
axillary  glands. 

Prognosis. — The  prognosis  is  always  grave.  It  is,  as  a  rule, 
more  favorable  in  childhood  and  youth  than  in  old  age.  It  is 
particularly  unfavorable  in  intemperate  persons,  and  in  individ- 
uals of  a  gouty  diathesis. 

The  ratio  of  mortality  varies  from  six  to  fifteen  or  twenty  per 
cent. 

Severe  headache,  early  and  extreme  prostration,  a  presenti- 
ment of  death,  long-continued  high  temperature,  constant  delir- 
ium, profound  stupor,  "  pin-hole  pupil,"  "  coma  vigil,"  subsultus 
tendinum,  carphologia,  a  copious  erupticn  and  a  feeble  heart 
impulse,  are  important  danger  symptoms.    The  danger  is  gen- 


!  consolidation,  is  sug- 
nsolidation  as  a  compli- 
fter  the  sixth  dav  of  the 
irally  visible. 
3S  closely  rf  sembles  ty- 
ower  temperature  range, 
absence  of  the  typhus 

J  resembles  typhus.  It 
rked  by  a  lower  range  of 
—and  by  the  absence  of 
isomnia  instead  of  head- 
tablish  beyond  a  doubt 

lant  form  which  prevails 
iiy  symptoms  of  typhus, 
us,  and  is  apt  to  be  asso- 
,se.   It  is  always  attended 

s  are  often  attended  by 
:  typhus,  and  when  the 
;ly  impossible  to  make  a 
ime  for  the  typhus  erup- 

it  it  is  highly  contagious, 
i  petechial  symptoms.  It, 
srter  course,  and  by  being 
ling  of  the  inguinal  and 

s  grave.  It  is,  as  a  rule, 
,h  than  in  old  age.  It  is 
5  persons,  and  in  individ- 

IX  to  fifteen  or  twenty  per 

3  prostration,  a  presenti- 
nperature,  constant  delir- 
"  " coma  vigil"  subsultus 
pticn  and  a  feeble  heart 
oms.    The  danger  is  gen- 


TREATMENT.  293 

-erally  proportionate  to  the  copiousness  of  the  eruption,  and  to 
the  severity  and  early  appearance  of  the  cerebral  symptoms. 

The  first  indication  of  recover n,  which  usually  appears  between 
the  tenth  and  the  fourteenth  days,  is  a  diminiition  in  the  fre- 
quency of  the  pulse,  accompanied  by  a  fall  of  two  or  three  de- 
grees in  the  temperature. 

Death  commonly  occurs  about  the  crisis,  but  may  take  place 
at  any  period.  It  may  occur  by  either  asthenia  or  coma,  but  is 
generally  due  to  complications. 

Treatment.— Proij/*/y/aa;js.— Typhus  fever  is,  in  this  country, 
almost  exclusively,  an  imported  disease.  And  its  epidemics  can, 
in  the  majority  of  cases,  be  traced  directly  to  the  introduction  of 
the  disease  through  infected  Irish  emigrants  who  land  in  New 
York  and  other  large  cities.  Hence  the  responsibility  of  its  occur- 
rence and  spread,  rests  entirely  with  the  national  authorities. 
Much  can,  however,  be  done  to  prevent  its  spread  after  it  is  im- 
ported, and,  as  guardians  of  the  public  health,  this  will  be  a 
part  of  your  duty. 

Upon  an  outbreak  of  an  epidemic  of  typhus,  the  strictest  san- 
itary measures  should  be  observed,  and  more  especially  in  local- 
ities where  there  is  over-crowding,  destitution  and  want.  The 
first  cases  of  the  fever  should  be  isolated  in  hospitals,  and  the 
dwellings  in  which  it  has  broken  out  should  be  depopulated  and 
thoroughly  disinfected  for  one  or  two  days,  before  the  rooms  are 
again  inhabited.  All  typhus  localities  should  be  immediately 
quarantined. 

There  is  no  known  prophylactic  treatment  for  typhus,  other 
than  isolation,  free  ventilation,  and  thorough  disinfection  of 
everything  contaminated  by  contagion.  Fresh  air  is  absolutely 
necessary.  All  the  windows  in  the  sick  room  should  be  kept 
open,  regardless  of  the  cold,  and  if  necessary,  the  patients  may 
be  covered  with  blankets  to  keep  them  warm.  In  hospital  prac- 
tice it  has  been  found  that  patients  do  better  in  open  tents,  than 
when  breathing  the  confined  air  of  hospital  wards.  Cleanliness 
is  of  the  utmost  importance;  all  the  excretions  should  be 
promptly  and  thoroughly  disinfected  with  Piatt's  chlorides,  or  a 
solution  of  carbolic  acid. 

During  typhus  epidemics  you  should  never  visit  a  typhus  pa- 
tient until  after  eating,  and  before  the  system  has  become  fa- 
tigued by  the  worry  and  care  of  the  day's  business.    Always 


i:>'*;dsg»w^«»irWsetfasa>'W9^TOittkJs^>>«»£^^ 


i 

f 

it 


rr 


294 


LECTURES  ON  FEVERS. 


make  your  visits  short,  avoid  inhaling  the  exhalations  from  the 
patient's  body,  and  remember  that  the  contagious  distance  is 
about  two  feet. 

After  recovery  or  death,  all  articles  worn  by  the  patient,  the 
room  and  all  its  contents  should  be  thoroughly  disinfected  by 
the  burning  of  sulphur  or  the  pouring  of  crude  carbolic  acid  on 
cliloride  of  lime.  The  bed  and  body  linen,  and  all  blankets  and 
flannels  that  have  been  about  the  bed,  should,  after  exposure  to 
the  disinfecting  gases,  or  immersion  in  some  disinfecting  fluid, 
be  thoroughly  boiled  or  baked.  Carpets,  if  they  have  been  per- 
mitted in  the  sick  room,  should  be  taken  up  and  fumigated,  and 
afterwards  beaten  or  shaken,  and  exposed  to  the  wind  and  sun- 
shine in  the  open  air  for  several  days.  The  mattrass  and  pillows 
should  be  burned.  After  everything  has  been  disinfected,  the 
wood-work  of  the  infected  building  should  be  thoroughly  cleaned 
with  carbolized  water  (one  part  of  acid  to  forty  or  sixty  of  water), 
the  walls  whitewashed,  and  the  rooms  freely  aired  for  at  least 
one  week. 

Principal  Remedies.— Oelsemium  is  indicated  when  the  fever 
sets  in  suddenly,  after  over  mental  exertion,  and  when  there  is 
great  prostration  of  all  the  vital  forces.  Baptisia  will  be  of 
service  early  in  the  disease,  when  there  is  intense  headache,  with 
extreme  depression  of  vitality,  and  desi  air  of  cure.  Bryonia  is 
called  for  during  the  first  week,  when  there  is  a  dry  cough,  with 
throbbing  or  darting,  tearing  pains  in  the  head,  aggravated  by 
Motion,  or  with  mild  delirium  about  business  affairs. 

Belladonna  v/hen  there  is  great  cerebral  congestion  with  throb- 
bing of  the  carotids,  or  furious  delirium.  Hyoscyanws  when 
the  cerebral  symptoms  are  more  adynamic,  and  the  patient  sinks 
into  a  state  of  apathy  and  stupefaction.  It  is  one  of  the  best 
remedies,  when  the  pains  in  the  head  are  very  severe,  or  when 
with  the  delirium  there  is  a  constant  desire  to  escape.  Also  if 
there  is  a  good  deal  of  mucous  rale.  Stramonium  will  be  of 
service  when  the  delirium  is  so  excessive  as  to  threaten  exhaus- 
tion.  Agaricus  is  called  for  when  ataxic  symptoms  are  present, 
and  when  with  tremor  and  restlessness  there  is  a  constant  desire 
to  get  out  of  bed.  Phosphoric  acid  when  there  is  great  nervous 
depression  with  slight  febrile  excitement.  Opium  if  wild  delir- 
ium  alternates  with  stupor  and  stertorous  breathing,  or  if  sopor 


LEADING   INDICATIONS. 


21)5 


i.\ 


lalations  from  the 
agiouB  distance  is 

y  the  patient,  the 
;hly  disinfected  by 
:le  carbolic  acid  on 
id  all  blankets  and 
,  after  exposure  to 
disinfecting  fluid, 
aey  have  been  per- 
md  fumigated,  and 
bhe  wind  and  sun- 
attrass  and  pillows 
en  disinfected,  the 
thoroughly  cleaned 
y  or  sixty  of  water), 
f  aired  for  at  least 

ated  when  the  fever 
and  when  there  is 
3aptisia  will  be  of 
3nse  headache,  with 
t  cure.  Bryonia  is 
s  a  dry  cough,  with 
lead,  aggravated  by 
i  affairs. 

agestion  with  throb- 
Hyoscyanws  when 
nd  the  patient  sinks 
is  one  of  the  best 
rery  severe,  or  when 
3  to  escape.  Also  if 
amonium  will  be  of 
i  to  threaten  exhaus- 
mptoms  are  present, 
1  is  a  constant  desire 
lere  is  great  nervous 
Opium  if  wild  delir- 
ireathing,  or  if  sopor 


threatens  to  terminate  in  paralysis  of  the  brain.  Arnica  if  stu- 
pefaction is  attended  with  involuntary  discharge  of  stool  and 
urine.  Rhus  iox.  for  involuntary  foetid  evacuations,  with  an 
accumulation  of  blackish-bnwn  mucus  on  the  tongue.  Arseni- 
cum alb.  for  uraDmic  convulsions,  and  when  with  involunta  y 
diarrhea  there  are  a  sunken  countenance  and  a  dry,  cracked 
tongue.  Opium  for  urasmic  coma,  and  for  urinary  retention. 
Muriatic  acid  in  advanced  stages,  when  there  is  complete  loss 
of  muscular  power,  and  low  delirium;  the  patient  is  so  weak  he 
settles  down  in  bed. 

Merc,  hi-jod.  is  the  remedy  for  inflammatory  swelling  of  the 
salivary  glands  ctnd  areolar  tissue  about  the  neck.  Seneya  or 
iart.  emet,  for  the  bronchitis.  Phosphorus  for  lung  complica- 
tions and  when  there  is  extreme  nervous  depression.  If  gan- 
grene threatens,  either  arsenicum  or  carbo.  vey.  will  be  needed. 
And  when  there  is  sudden  sinking  of  the  vital  forces,  with  apa- 
thy, muttering  delirium,  and  an  intermittent  pulse,  veratrum  alb. 
may  do  you  excellent  service. 

Leading  Indications.— The  guiding  symptoms  for  these  and 
other  remedies  of  use  in  typhus,  may  be  compiled  as  follows: 

Aconite.— Great  fear  of  death;  he  predicts  the  day  he  will 
die  (ars.).  Sensation  of  emptiness  in  the  head  (coccmZms).  Full- 
ness and  heaviness  in  the  forehead,  as  if  the  brain  would  start 
out  of  the  eyes  {bell,  bry.).  Burning  headache,  as  if  the  brain 
were  moved  by  boiling  water.  Active  inflammatory  symptoms. 
In  sanguine  and  plethoric  individuals. 

Agaricus  mnsc. — Disinclination  t'^  answer  questions  (phos. 
acid).  Desire  for  alcoholic  drinks.  Sensitive  smell  (colch.). 
Dry  tongue  with  dryness  and  constriction  in  the  fauces.  Rumb- 
ling in  the  bowels  with  the  passage  of  much  inodorous  flatus. 
Delirium  with  constant  raving,  tries  to  get  out  of  bed  (hyos.). 
Contracted  pupils;  dry,  tremulous  tongue.  Frequent  pulse, 
with  weakness  of  the  first  sound  of  the  heart.  Trembling  of  the 
hands.  Pains  in  the  legs,  especially  in  the  hip  joints.  Twitch- 
ings  of  the  gluteal  muscles.     Cramps  of  the  hands  and  feet. 

Apis  mel.— Stupor  with  muttering  delirium.  Sopor,  inter- 
rupted by  piercing  shrieks.  Tongue  swollen,  dry,  cracked,  ul- 
cerated and  protruded  with  difficulty  {ars.,  rhus).  Great  sore- 
ness in  the  pit  of  the  stomach  when  touched  {bry.).    Soreness 


BMiimilittiiiiif I  hiim 


29(J 


LECTURES   ON   FEVEltS. 


and  bloatedness  of  the  abdomen  (lach.).  Frequent,  foul,  invol- 
untary stools.  Suppression  of  urine  {hyost.,  opium).  White 
miliary  eruption  on  the  chest  and  abdomen.  Great  weakness 
and  sliding  down  in  bed  {nrnr.  acid).  Carbuncles  with  burning, 
stinging  pains  {ars.).  Accumulation  of  tough  mucus  in  the 
throat. 

Arnica. — Stupefaction  with  foetid  breath,  and  large,  yellowish- 
green  spots  on  the  skin.  Great  weariness  compelling  the  patient 
to  lie  down,  and  yet  he  asserts  that  he  feels  perfectly  well  (ars. ). 
Forgets  the  words  while  speaking  (rims).  Declines  to  answer 
questions  {phos.  acid).  Confused  feeling  in  the  head  with  pres- 
sure over  the  right  brow.  Unrefreshing  sleep  with  anxious 
dreams.  Muttering  and  loud  blowing  during  expiration.  Desires 
to  be  constantly  moved,  the  bed  feels  too  hard  (bapt).  Dryness 
of  the  lips  and  tongue.  Trembling  of  the  lower  lip.  Brown 
streak  through  the  center  of  the  tongue  (bapt).  Involuntary 
discharge  of  urine  and  faeces  {ars.,  hyos.).  Petechise.  Ecchy- 
moses. 

Arsenicum  alb. — Great  restlessness  and  anxiety.  Predicts 
the  day  he  will  die  {aconite).  Constant  motion  of  the  head  and 
limbs.  Death-like  color  of  the  face  {carbo.  veg.).  Sunken,  hip- 
pocratic  countenance  {verat.  alb.).  Staring,  glistening,  sunken 
eyes.  Hardness  of  hearing.  Lips  dry,  cracked  and  covered 
with  sordes.  Tongue  red,  dry  and  cracked  {bry.,  rhus).  Black, 
leather-like  tongue.  Dryness  of  the  mouth  with  violent  thirst; 
drinks  often,  but  little  at  a  time  {bell,  cinch.,  opp.  bry. ).  Unin- 
telligible articulation,  as  if  the  tongue  was  too  heavy  {carbo.veg.). 
Intense  burning  pains  in  the  stomach  and  pit  of  the  stomach 
{phos.,  verat.  alb. ).  Violent  and  incessant  vomiting.  Involun- 
tary micturition  ( hyos. ).  Weak,  tremulous,  hoarse  voice.  Short, 
anxious,  rattling  breathing,  with  great  anguish.  Very  tenacious 
mucus  in  the  chest  {kali  bich.,  tart.  anet. ).  Extensive  pulmonary 
hypostasis.  Pulse  frequent,  hard  and  tense,  or  small,  trembling 
and  intermittent.  Irregular  action  of  the  heart,  absence  of  the 
second  sound.  White  miliary  eruption  {lach.,  mur.  acid).  Pe- 
techise {rhus,  secxile,  am. ).  Boils  {mere,  sil,  std. ).  Carbuncles, 
which  burn  like  fire  (  caust,  mere,  sil. ).  Bapid  prostration  of 
strength  {aconite,  verat.  alb.). 

Arum  tripli.— Soreness  of  the  lips  and  corners  of  the  mouth. 


•W-WR^— --W^t-' 


A'^fij^^iK^i'm 


1 


LEADING   INDICATIONS. 


297 


requent,  foul,  invol- 
st.,  opium).  White 
n.  Great  weakness 
mcles  witli  burning, 
}ugli  mucus  in  the 

and  large,  yellowish- 

mpelling  the  patient 

)erfectly  well  {ars. ). 

Declines  to  answer 

the  head  with  pres- 

sleep  with  anxious 

expiration.  Desires 

rd  (bapt).  Dryness 

I  lower  lip.    Brown 

)apt ).    Involuntary 

Petechise.     Ecchy- 

l  anxiety.  Predicts 
tion  of  the  head  and 
!7e</.).  Sunken,  hip- 
T  glistening,  sunken 
•acked  and  covered 
bry,,rhus).  Black, 
.  with  violent  thirst; 
,,  opp.  bry. ).  Unin- 
o heavy  {cnrbo.veg.). 
1  pit  of  the  stomach 
vomiting.  Involun- 
boarse  voice.  Short, 
ish.  Very  tenacious 
Ixtensive  pulmonary 
,  or  small,  trembling 
leart,  absence  of  the 
j/t.,  mur.  acid).  Pe- 
.,  sul. ).  Carbuncles, 
Japid  prostration  of 

oruers  of  the  mouth. 


Swelling  of  the  sub-mnxillary  glands  and  neck  {mere.  bi-Jnd). 
Sore,  red  tongue  with  elevated  papillie.  Fcetid  breath.  Boring 
of  tlie  nose;  picking  the  ends  of  the  fingers.  Symptoms  of 
uremic  poisoning  {ars.,  opium). 

fiaptisia. — Confusion  of  ideas  (ych.,  rhns).  Great  nervous 
restlessness,  especially  at  night.  Dull,  stupefying  headache 
{(fcls.).  Head  feels  as  if  scattered  about;  tries  to  get  the  pieces 
together  {stram.).  Falls  asleep  in  the  midst  of  attempted  an- 
swers {am.,  hyos.).  Dark,  red  face,  with  besotted  expression. 
Numbness  of  the  head  and  face.  Tongue  coated  brown,  and 
dry,  particularly  in  the  center.  Feeling  as  if  the  lower  limbs 
were  severed  from  the  body  {opium).  Sensation  as  of  a  second 
self  alongside  in  bed.  The  hands  feel  too  large.  Soreness  of 
the  iiesh;  the  bed  on  which  he  lies  feels  too  hard  {am.,  rhns). 
Offensive  secretions. 

Belladonna. — Starting,  jumjung  during  sleep.  Sleepiness, 
with  inability  to  sleep  {lack.,  opium).  Violent  delirium.  Con- 
stant desire  to  spring  out  of  bed  {agar.,  hyos.).  Attempts  to 
bite,  strike  and  spit  at  attendants  {hyos.,  opimu).  Violent 
throbbing  in  the  brain.  Throbbing  of  the  carotids  {glon.),  and 
great  intolerance  of  light  and  noise  {aco.,  opium).  Pressive 
pain  in  the  forehead,  as  from  a  heavy  weight,  obliging  him  to 
close  the  eyes  {puis.).  Sparkling,  staring  eyes  {hyos.,  stmm.). 
Dilated  pupils  {gels.).  Humming,  roaring  and  tingling  in  the 
ears.  Glowing  redness  of  the  face,  or  else  great  paleness  {bry.). 
Dryness  of  the  mouth,  tongue  and  throat.  Tongue  red  at  the 
edges  and  white  in  the  center  {gels. ).  Trembling  and  heaviness 
of  the  tongue  with  stammering  speech  {lack.).  Difficult 
deglutition;  fluids  swallowed,  return  through  the  nose  {kalibich., 
lack.).  Involuntary  micturition  and  defecation.  Tendency  to 
slide  down  to  the  foot  of  the  bed  {mtcr.  acid).  Dry,  spasmodic 
<5ough,  worse  at  night  {dros.,  hyos. ).  Jerking  of  the  bedclothes. 
Starts  as  if  in  affright  on  awaking  or  during  sleep  (ars.). 

Bryonia. — Exceedingly  irritable,  everything  makes  him  angry 
(cham.)  Nightly  delirium,  especially  about  the  affairs  of  the 
previous  day,  or  business  matters.  Desire  to  escape  from  bed 
and  go  home.  Vertigo  with  sensation  as  of  the  head  turning  in 
a  circle  {bell).  Visions  when  closing  the  eyes.  Buzzing  in  the 
ears  with  hardness  of  hearing.     Red,  bloated,  hot  face.     Dry, 


ww«ii'iWM[>'BmrwimiiNi«ii<iifc.»»i.ii*iiiiiiiwiMiiii 


I 

■•'! 


g|§  LECTUHES   ON    lEVERS. 

parched  and  cracked  lips.  Tongue  dry,  rough  and  cracked,  often 
of  a  dark-brown  color.  White  or  yellow  coating  on  tongue.  Ex- 
cessive  thirst,  drinks  laige  quantities  at  a  time  and  at  long  in- 
tervals. Nausea  and  faintness  on  rising.  Stitches  hi  the  liver 
and  spleen  {mere. ).  Constipation.  Cough,  with  stitches  in  the 
chest,  and  expectoration  of  tenacious,  rust-colored  sputa  {])lios., 
rhns).  Typhoid  pneumonia.  Restless  t-leep  with  moaning  and 
with  chewinq  motions  {hell).     Great  weakness  and  exhaustion. 

Camphor.— Sudden  and  great  sinking  of  strength  (ars  ). 
Extreme  lestlessness  and  anxiety  {ars  ).  Cold  sweat  all  over  the 
body  {vcvdl.  (ilh).  Cold,  pointed  nose.  Face,  pale  and  anxious. 
Sudden  sinking  spells.  Small,  weak,  scarcely  perceptible  pulse 
{airho.  vi'tj  ).  Violent  delirium.  Great  thirst;  coldness  of  the 
tongue  {ccirbo.  veg  ,  verui.  alb.).  Rattling  in  the  throat,  invol- 
untary  evacuations. 

Carbo.  veg.— Restlessness  and  anxiety.  Greenish  color,  or 
great  paleness  of  the  face  {ars  )  Hippocratic  countenance 
{veral.  alb. ).  Coldness  of  the  bieath  and  tongue,  at  times  the 
tongue  is  moist  and  sticky;  at  others  it  is  dry  and  cracked. 
Hawking  of  mucus  in  the  throat.  Internal  burning,  wants  to  be 
fanned  (ors.)  Loud,  rattling  bieathing.  Cough,  with  greenish, 
foetid  expectoration  [sil ).  Paralysis  of  the  lungs  with  blueness 
of  the  face,  lips  and  tongue.  Thread-like,  scarcely  perceptible 
pulse.     Ecchymoses. 

Cinchona.— Sense  of  internal  illness,  as  of  impending  disease. 
Pressure  in  the  head  from  within  outwards,  as  it  it  would  burst, 
relieved  by  hard  pressure.  Whizzing  in  the  ears,  with  hardness 
of  hearing  {phos..  rhns).  Bitter  taste  in  the  mouth ;  obstinate 
constipation.  Empty  eructations;  milk  deranges  the  stomach 
{snlph  ).  Enlargement  of  the  livei  and  spleen.  Profuse  sweat 
during  sleep,  especially  on  the  side  on  which  the  patient  lies. 
Great  weakness.     Protracted  convalescence. 

CoccuhlS.— Slowness  of  comprehension.  Vertigo  with  nausea 
when  rising  up  in  bed  (bry  );  must  lie  down.  Heaviness  of  the 
lids,  with  unconquerable  sleepiness.  Drowsiness  lapsing  into 
coma.  Stupor;  coma  vigil.  Noise  in  the  ears  like  the  rushing 
of  waters.  Tremulousness;  automatic  motions.  Weakness  of 
the  cervical  muscles.     Drink  rolls  audibly  down  the  throat  into 


ia«ns'-^--yfe.jjar-^;as:g"j^ggeg»l 


mmmmititstmmillt^^ 


LEADINQ   INDICATIONS. 


299 


li  nnd  cracked,  often 

ing  on  ton{j[iit>.    Ex- 

ime  aud  at  long  in- 

Stitchefe  jn  the  liver 

with  stitches  in  the 

olored  sputa  {])ltos., 

pp  with  moaning  aud 

less  and  exhaustion. 

of  strength  (nrs), 
old  sweat  nil  over  the 
,cp,  pale  and  anxious, 
ely  perceptible  pulse 
lirst;  coldness  of  the 

in  the  throat,  invol- 

Greenish  color,  or 
jocratic  countenance 
tongue,  nt  times  the 
is  dry  anil  cracked, 
burning,  wants  to  be 
!ough,  with  greenish, 
3  lungs  with  blueness 
scarcely  perceptible 

»f  impending  disease. 
,  as  if  it  would  burst, 
e  ears,  with  hardness 
the  mouth;  obstinate 
(ranges  the  stomach 
leen.  Profuse  sweat 
Ich  the  patient  lies. 

Vertigo  with  nausea 
Q.  Heaviness  of  the 
vsinesB  lapsing  into 
irs  like  the  rushing 
ions.  Weakness  of 
[iown  the  throat  into 


the  stomach   {lanr.,  hydr.  acid).     Great  general  weakness  nnd 
weariness  after  over-exertion  {(igdi'icun). 

(jelseillhllll.— Dullness  of  the  mental  faculties  (bapf.).  Drow- 
siness, vertigo,  and  great  muscular  prostration.  Heaviness  of 
tlie  head,  relieved  after  jjrofuse  emission  of  watery  urine  (j>hos. 
(tcid).  Vertigo  and  blurred  vision  {iris  vers.).  The  brain 
feels  as  if  bruised  {bell.).  Head  feels  as  "big  as  a  bushel." 
Cephalalgia  with  lancinating  pains  extending  from  the  left  oc- 
cipital region  through  the  head  to  the  forehead  and  eyeballs. 
Pain  as  from  a  tape  around  the  head  {mere. ).  Drooping  of  the 
eyelids  {rhus).  Great  aversion  to  light,  with  dilatation  of  the 
pupils  (bell,).  Heavy,  besotted  expression  (bapt.).  Crimson 
flush  of  the  face.  Tongue  coated  yellowish-white,  with  foetid 
breath.  The  tongue  trembles  so  he  can  hardly  protrude  it  (hell., 
lack.,  secale).  Predominance  of  nervous  symptoms  (phos.). 
Complete  prostration  of  the  Avhole  nervous  system  {ctmicifnya). 

Helleborus  nig. — Sensation  of  soreness  in  the  back  of  the 
head  with  stupefaction.  Eyes  vacant,  pupils  dilated  ( bell.,  hijos.). 
Insensibility.  Chewing  motions  of  the  jaws  (6r»/.).  Convulsive 
twitchings  of  the  muscles  {cupr. ).  Constant  picking  of  the  lips 
and  bedclothes.  Sliding  down  in  bed  {mnr.  acid).  Small,  slow, 
tremulous  pulse.  Suppression  of  urine,  or  highly  albuminous 
urine.    Trifling  loss  of  flesh. 

Hyoscyamus. — Complete  loss  of  consciourness  {bell,  opium). 
Muttering  with  picking  at  the  bedclothes  {opium).  Muttering 
loquacity  (apis).  Answers  questions  correctly,  when  asked,  but 
lapses  again  into  delirium  {arnica,  bell).  Whines  and  dont 
know  why.  Coma  vigil.  Delirium  continues  while  awake;  sees 
persons  who  are  not,  and  who  were  not  present.  Jumping  out 
of  bed.  Thinks  he  is  in  the  wrong  place.  Attempts  to  run 
away.  Desires  to  uncover  aud  remain  naked.  Flushed  face, 
stupid  expression  {bapt).  Red,  sparkling,  stariiij^  eyes  {bell.). 
Objects  appear  too  large  or  red  as  fire  (opp.  plat.).  Pupils  di- 
lated {bell,  opp.  phos.)  and  insensible  {opium).  Constrictive 
sensations  in  the  throat  with  inability  to  swallow  {bell,  stram.). 
Clean,  parched,  dry  tongue.  Hiccough;  putrid  breath.  Invol- 
untary stools  at  night  {ars.,  rhus).  Retention  of  urine  {opium). 
Involuntary  urination.  Grating  of  the  teeth  {apis.  hell). 
Trembling  of  the  limbs.    Subsultus  teadinum.    Hypersesthesia 


Sja.-9Mhe-itt*S('J»^Si^.t**«^;H;»w.sss'- 


I- 


300 


LECTUnEH  ON   FEVEllR. 


■of  tho  skin.     Brown  spots,  or  gangrenous  vosicles  on  the  body. 
Grout  nervous  excitiibility  without  much  cerebral  hyperaDraia. 

Liichesls.— Great  mental  ami  physical  exhaustion.  Sleepi- 
ness, witli  inability  to  sleep.  Aggravation  of  all  the  symptoms 
after  sleep.  Headache,  mostly  in  the  forehead  witli  nausea  and 
cliilliness  (puln.).  Loquacious,  constantly  changing  from  one 
subject  to  another.  Stupor  and  muttering  delirium  (apis). 
Sunken  countenance.  Dropping  of  the  lower  jaw  (lyco]).,  opi- 
tnii).  Dry,  red  or  black,  cracked  and  bleeding  tongue  {ars.). 
Trembling  of  the  tongue  when  protruding  it  {bell.,  fjcls.).  In 
putting  the  tongue  out  it  catches  on  the  teeth  or  under  lip.  Dry, 
cracked  and  bleeding  lips.  Variable  appetite.  Desire  for  oys- 
ters (lye.).  Hyperajsthesia  of  the  abdomen.  Alternate  diarrhea 
and  constipation.  Dyspnoea.  Hawking  of  mucus  Avith  rawneBs 
in  the  throat.  Burning  in  the  chest  (opp.  rtrs.).  Irregularity 
of  heart-beat  (digit.).  Carbuncles  surrounded  by  small  boils 
and  purple  spots.  Falling  off  of  the  hair  (mere,  phos.).  In 
intemperate  persons. 

Lycopodium. — Depression  of  spirits  (nai„  puis.).  Afraid  of 
being  alone  (ars..,  opp.  niiiX').  Uses  wrong  words  to  express  an 
idea  (ai'n.,  nnac,  (jraph.).  Restless  sleep.  Pressing  headache 
on  the  vertex,  worse  from  lying  down.  Tearing  pain  in  the  oc- 
ciput (con).  Putrid  smell  from  the  mouth.  Roaring,  humming 
and  whizzing  in  the  ears  (cinch. ).  Tongue  coated  white,  or  else 
red  and  dry,  Vesicles  on  Ihe  tongue.  The  tongue  is  thrust 
spasmodically  to  and  fro  between  the  teeth.  Dropping  of  the 
lower  jaw  (lack.,  mur.  acid,  opium).  Fan-like  motion  of  the 
aire  nasi.  Desire  for  sweet  things.  A  little  food  seems  to  fill 
the  stomach  full,  and  causes  fullness  and  distension  of  the  abdo- 
men, The  urine  leaves  a  red,  sandy  stain  on  the  sheet  (cinch., 
Xihos,).  Chilliness  in  the  rectum  before  stool.  Scanty  stool 
with  a  sensation  as  if  much  remained  behind.  The  hair  becomes 
gray  early.    Falling  out  of  the  hair  (graph.,  mere,  phos.). 

Mercnrius. — Great  restlessness,  weariness  and  prostration. 
Heavinesb  of  the  head  with  great  inclination  to  sleep.  Swollen, 
soft,  flabby  tongue,  taking  the  imprints  of  the  teeth.  Putrid 
odor  from  the  mouth.  The  tongue  is  coated  with  a  dirty-yellow 
fur;  feels  as  if  burnt  (colocynih).  Region  of  the  liver  painfnl 
and  sensitive  to  contact  (hdl.,  hry.).     Swelling  and  suppuration 


IS. 

svosicleB  on  the  body, 
cerebral  liyperaBinia. 

al  exhaustion.  Sleepi- 
n  of  all  the  symptoms 
•ehead  witli  nausea  ond 
tly  changing  from  one 
iring  delirium  (apis). 
lower  jaw  {hjcop.,  opi- 
leeding  tongue  {ars.). 
ng  it  {bell.,  (jch.).  In 
fteth  or  under  lip.  Dry, 
petite.  Desire  for  f)y8- 
en.  Alternate  diarrhea 
of  mucus  Avith  rawness 
pp.  <irs.).  Irregularity 
•ounded  by  small  boils 
air  {mere,  phos.).     In 

nat„  pills. ).  Afraid  of 
mg  words  to  express  an 
sp.  Pressing  headache 
Tearing  pain  in  the  oc- 
th.  Roaring,  humming 
ue  coated  white,  or  else 
The  tongue  is  thrust 
eeth.  Dropping  of  the 
Fan-like  motion  of  the 
little  food  seems  to  fill 
distension  of  the  abdo- 
in  on  the  sheet  {cinch., 
re  stool.  Scanty  stool 
and.  The  hair  becomes 
'pk.,  mere,  phos.). 

riness  and  prostration, 
tion  to  sleep.  Swollen, 
i  of  the  teeth.  Putrid 
ited  with  a  dirty-yellow 
ion  of  the  liver  painfnl 
veiling  and  suppuration 


LEADINQ   INDICATIONS. 


8^ 


of  the  inguinal  ghuids  (iiif.  odd).  Frequent  urination,  the 
urnio  leaves  a  whitisli  setliment.  Icteroid  hue  of  tlio  sitni.  Hu- 
(Itunina. 

Muriatic  acid.— When  decomposition  of  the  fluids  is  slow 
and  extensive.  Continuous  deluinm;  vivid  hallucinations.  The 
patient  is  busied  with  past  and  jjresent  (n-ents.  Sleepiness  in 
tlie  daytime,  sleeplessness  at  night  with  muttering  delirium. 
Constant  inclination  to  slide  down  in  bod.  Glistening  eyes; 
contracted  pupils.  Acuteness  of  the  special  senses.  Excessive 
dryness  of  the  lips,  mouth  and  tongue.  T(mgue  heavy,  like  lead,, 
preventing  talking.  The  lower  jaw  hangs  down  {loch.,  hjcop., 
opinrn).  Involuntary  micturition  and  defecation.  Pulse  rapid 
anil  very  feeble,  intermits  every  third  beat  {iiU.  acid).  Acceler- 
ated breathing.     Great  prostration. 

Niix  vom.  —Over-sensitiveness  to  external  impressions  (r/)/c/<.). 
Delirious  phantasies  only  on  lying  down.  Chilliness  on  slight 
movement.  Dryness*  of  the  mouth  and  tip  of  the  tongue.  Hun- 
ger with  aversion  to  food  {opium).  Flatulent  distension  of  the 
abdomen  after  eating  (cinch.,  h/cop.).  Alternate  constipation 
and  diarrhea.  Throbbing  in  the  region  of  the  liver  {hri/.). 
Numbness  and  deadness  of  the  lower  limbs.  Heaviness  of  the 
body  (opp.  sepia).     In  thin,  slender  persons. 

Opium. — Drowsiness  or  sopor.  Complete  loss  of  conscious- 
ness ( hyos. )  with  slow  stertorious  breathing.  Symptoms  resemb- 
ling delirium  tremens.  Stupid  sleeplessness  with  frightful 
visions.  Suffocating  nightmare.  Muttering  delirium.  Attempts 
to  iescape  {bell,  hyos.).  Contracted  j)\ipi\s  (hyos., physostigma). 
Glassy,  half-closed  eyes.  Face  dark-red,  bloated,  hot  (hell.) 
flushed  ( hyos  ),  or  pale  and  sunken.  Bed  feels  hot,  can  hardly 
lie  on  it.  Difficult,  intermitting  breathing,  as  from  paralysis  of 
the  lungs  (lye,  tart  emet).  Deep  snoring,  slow  breathing  with 
open  mouth.  Convulsive  movements  and  numbness  of  the  limbs. 
Retention  of  urine.  Involuntary  stools.  Picking  at  the  bed- 
clothes (hyos.).  Dropping  of  the  lower  jaw  (lach.,  mur.  acid). 
In  children  and  old  people. 

Phosphorus. — Constant  sleepiness.  Low  muttering  delirium 
(am.,hapt.,  rlnn).  Coma  vigil.  Inability  to  concentrate  thought 
(am.,  rhiis).  \Jarphologia  (am.,  hyos.).  Contracted  pupils. 
{opium,   physostigma).     Humming  and  roaring  in  the  head. 


niMUMKnilBdHliiliiiiH 


302 


LECTUIlEfi  ON    FEVEKH. 


Tln'ol)l)int;  in  the  eiux  (cdlc),  loiul  whizzing  before  the  eai-s 
inirrc  ).  DulliifSH  of  hearing,  piirtu'ulnrly  of  the  hniniin  voice. 
Pah',  .sallow  couiplfxioii.  Dry,  iinniovablc  toiiKUo,  cracked  and 
covered  with  Kordet*  Uirs.,  rcr<il.  <ilh.).  Thirnt  with  desire  for 
very  cold  drinks  {rlins).  Region  of  stonuvch  painful  to  touch. 
Feelinu  of  coldness  in  the  abdomen  ( <(rs.,i<fpi(i ).  Brown  urine, 
depositing  a  brick-dnst  sediment  (cinch.,  hfc. ).  Hard,  diy  cough 
with  oppression  of  the  chest.  Lond  mucous  rales  iji  the  lower 
lobes  {ijM'cdcJart  emct).  Hepatization  of  the  lungs.  Small, 
(luick,  easily  compressed  pulse.  Heaviness  of  the  lower  limbs. 
Ecchymoses. 

PhoMplioi'iv  acUI.— Perfect  indifference  {cinch.,  lye).  Disin- 
cliimtion  to  talk  {hrll,  phos.,  opp.  sfmm.).  Incapacity  for 
thought  (grh.).  Answers  questions  slowly  and  reluctantly  or 
short  and  incorrectly  {jthos).  Somnolence  with  muttering  de- 
lirium. Headache,  worse  from  the  least  shaking  or  noise  {hell., 
lali  bich)  Deafness  with  roaring  in  the  ears.  Dryness  of  the 
tongue  and  throat  without  thirst  (nnx).  Desire  for  refreshing 
or  juicy  things  {puis.,  rcrat.  (dh.).  Feeling  of  heaviness  in  the 
region  of  the  liver.  Involuntary  stxiols.  Frequent  emission  of 
pale,  watery  urine,  forming  a  milky-white  cloud,  especially  at 
night.  Frequent,  small,  feeble  pulse.  Cough  with  purulent, 
oflfensive  exj)ectoration  (ar.s.  shZ;>/«.  V  Bluish-red  spots  on  the 
parts  upon  which  the  patient  lies.  Profuse  night  {mere)  and 
moniing  {cinch.)  sweats.  In  young  persons  who  have  grown 
very  rapidly. 

Rhus  fox.— Great  restlessness  and  uneasiness  {ars.)-  Inco- 
herent muttering.  Answers  qiiestions  correctly  but  slowly  {bry.. 
hepnr).  Desire  to  commit  suicide  ( hepnr,  mix)  Active  delir- 
ium and  great  prostration.  Vivid,  troublesome  dreams  of  exces- 
sive  bodily  exertion.  Fullness  and  heaviness  in  the  forehead, 
worse  from  opening  or  moving  the  eyes  {jmh.).  Dark,  livid 
redness  of  the  cheeks.  Dry.  red,  cracked  tongue  {hapt,  bell). 
Redness  of  the  tip  of  the  tongue  in  the  shape  of  a  triangle. 
Putrid  taste  and  breath.  Induration  of  the  parotid  and  sub- 
maxillary glands.  Great  thirst  for  cold  drinks  {phos. )  especially 
cold  milk.  Involuntary  fetid  stools  during  sleep.  Dry,  tickling 
cough,  worse  in  the  evening  and  before  midnight  Infiltration 
of  the  lower  lobes  of  the  lungs.  Erysipelas  with  great  burning. 
Glandular  swellings. 


uiji  iMBumijiiii  mt 


■f*! 


LEADING   INDICATIONS. 


803 


?zinR  before  the  efti-s 
ly  of  tho  hntniin  voice. 
I(>  toii^iHs  criu'ked  niul 

ThiiHt  with  (losne  fur 
iruicli  painful  t«)  toucli. 

srpid ).  Brown  urine, 
'//('. ).  Hard,  dry  cough 
couH  rales  in  tho  lower 
1  of  the  lungs.  Small, 
088  of  the  lower  limbB. 

B  {cinch.,  lye).    Disin- 
am.).     Incapacity   for 
»wly  and  reluctantly  or 
ice  with  muttering  de- 
shaking  or  noise  {bell., 
»  ears.     Dryness  of  the 
Desire  for  refreshing 
ling  of  iieaviness  in  the 
Frequent  emission  of 
ite  cloud,  especially  at 
Cough  with  purulent, 
Jluish-red  spots  on  the 
use  night  {mere.)  and 
rsons  who  have  grown 

[easiness  {ars.)-  Inco- 
rrectly hut  slowly  {hry., 
tr,ntix)  Active  del ir- 
esorae  dreams  of  exces- 
viness  in  the  forehead, 
^8  (]yuls.).  Dark,  livid 
d  tongue  {hapt,  hell.). 
he  shape  of  a  triangle. 
f  the  parotid  and  sub- 
rinks  {phos. )  especially 
ng  slee}).  Dry,  tickling 
midnight  Infiltration 
jlas  with  great  burning. 


•  SPCale  corn.— Constant  sighing.  Oreut  prostration  and  ex- 
treme resth'ssnt'-'^s.  Maniii  with  inclination  to  bit<*  (/«•//.,  siniw.). 
Avernion  to  l)eing  covfrcd.  Anxioty  an»l  burning  at  tlit»  pit  of 
the  stomach  {(i.r».).  l'\'ar  of  death  {(irs).  Cold  perspiration 
on  the  face  and  forehend.  Brown  or  blackish  tongue  {<u-».). 
Vii>lent,  unquenchable  thirst.  Hici-ough  {(ir».,  mij-  uios.).  In- 
voluntary diarrhea  {hijoH.).  Suppression  of  urine.  Great  trem- 
bl  ing  when  uttenipting  to  move.  Fuzzy  feeling  in  the  extremities. 
Extensive  ecchytnoses. 

StraillOlllHIIl.— Stupid  indifference  (p/io.s.  nciil).  Desires 
light  and  company  (opj). ////««. ).  Lo<iuacious  delirium  {hich., 
hichiumfhca).  Furious  tloliriura;  strange  fancies;  and  desire 
to  go  home  {hri/.).  Indomitable  rage,  and  desire  to  bite  {hell., 
secale).  Wide  ojjen,  staring  eyes  (hell.,  liyos.).  Transient  loss 
of  sight,  hearing  and  speech.  Oblique  vision.  Violent  thirst, 
especially  for  sour  drinks  (ftr?/.,  secale).  Yellowish-brown  coat- 
ing on  tho  tongue  which  is  dry  in  the  center  {h(ij)t.).  All  food 
tastes  like  straw  {suli:h.).  Black  stools  which  smell  like  carrion 
{ars.,  varho.  ihuj.).  Suppression  of  urine  or  else  involuntary 
urination.  Constant  restlessness  w  ith  jerking  motions  of  the 
limbs  and  of  the  whole  body.  Carphologia.  Subsultus  tendi- 
num. 

Hlilphuric  acid.— Irascibility.  Hardness  of  hearing  {o(ilc., 
sulph. ).  Dry,  red  or  brown  tongue.  Aphthro.  Swelling  and 
inflammation  of  the  sub-maxillary  glands.  Violent  hiccough 
{sec(ile).  Dark,  persistent  hemorrhages.  Blue,  ecchymotic  spots 
{carho.  veg.,  phos.  (icid).     Gi'eat  weakness  and  prostration. 

Tartar  eniet. — Stupefying  headache  with  pressure  from  with- 
out inwards,  in  the  forehead  and  over  the  root  of  the  nose. 
Irresistible  inclination  to  sleep.  White,  pasty  coating  on  the 
tongue.  Tongue  red  in  streaks  and  dry  in  the  middle  (r/tM.s). 
Continuous  anxious  nausea  {ipecac).  Violent  and  painful  urg- 
ing to  urinate  with  scanty  or  bloody  discharge  ( can.  sat. ).  Great 
rattling  of  mucus  in  the  chest  {ipecac).  Cough  with  suffocative 
attacks.     Threatened  oedema  of  the  lungs  {moschus). 

Veratruiil  alb. — Desire  to  bite,  strike  or  tear  things  {hell, 
slram.).  Coma  vigil  Avith  frequent  starts,  as  if  from  fright. 
Sudden  sinking  of  strength  {ars.,  camph.).  Hippocratic  coun- 
tenance.   Cold  perspiration,  especially  on  the  forehead.    Sunken 


WtUi'liW 


■I  iWIU«AMMMtoliMIMWh><L 


1» 


304 


LECTUIIKS   ON    FEVF.UW. 


ov.«s;  pnint.-.l  n.mo.  T<.nKno  .-..hi  ( mrhn.  ny. ),  or  C(wito.l  whito 
with  r.-.l  tip  Hiul  .«.1k.>h.  Violoiit  thiiHt  for  c.Ul  wntrr  (ar«..  /*//o«.^ 
SpiiHincHlii"  (•niirttiicti..n  <.f  tl.n  tl.nmt  (////ox.).  SuppreHHwm  of 
u,ii,.>.  !<•>'  coUlnoHH  ..f  th.'  luuulH  iumI  foot.  Peteohiiu  on  the 
extromitioH. 

Vrnitniiii  vir.-MuttoriiiK  (Iclirium.  IlontlPHs  blnop,  with 
tlro.iuiH  ..f  l..>in«  (In.wuo.l.  H.-mlacho.  tho  p.iitm  boKin  i»  tho 
fcrolioml  luul  run  buck  ti)  tli.^  ..ccipnt  n\u\  spin.'.  Tho  oyoH  ro- 
nuiin  opon  nm\  th.«  pu|.ilH  iiro  .liliit...!.  Tho  faco  is  tlushod.  ..r 
elso  pah>  luul  oovorcl  with  c.Id  porspiviition.  Tho  ton^uo  m 
cofttod  whitH  or  yoUow,  witli  h  nul  stroaii  down  tho  center.  Tho 
puUe  is  inefruhir,  hard  and  frHtpuMit, and  tho  lioartbeatH  rapidly 
whoa  turning  over  in  bed  (hrll.).  OppresHiun  „f  the  chest  witli 
Blow,  labored  IneatliinK-  Involuntary  .urination.  Hiccough. 
8ub8ultu8  tendinum.     Heart  failure.  .     ' 

ZllK'Um.— Weakness  of  memory  ( af/ac. )  Brain  exhaustion. 
Delirium,  with  attempts  to  get  out  of  bed  {lifjos.).  Constant 
jerking  of  tho  whole  body  duriiig  sleep.  Cnrphologia.  Subsul- 
tus  tendinum.  Sliding  down  in  bed  (miir.  acid).  Involuntary 
evacuations. 

HYGIENIC    AND    DIETETIC    TKEATMENT. 

The  sick  room  should  be  large  and  ncll  ventilated,  for  in  ty- 
phus fever  bad  air  is  more  to  be  dreaded  than  ventilation.  Al- 
ways allow  pUmty  of  fresh  air  to  circulate  about  tfie  patient,  day 
and  night.  For  asylums,  the  hospital  tent  will  always  be  better 
than  the  hospital  ward. 

Carpets,  all  unnecessary  furniture,  and  everything  that  is  liable 
to  absorb  and  retain  contagion  should  be  removed  from  the 
apartment.  The  patient  should  go  to  bed  as  soon  as  the  fever 
appears.  All  unnecessary  visiting  should  be  prohibited.  All 
mental  and  bodily  effort  should  be  avoided.  Throughout  the 
whole  course  of  the  disease,  quietude  and  the  strictest  cleanli- 
ness  should  be  observed.  Piatt's  chlorides  diluted  one  part  to 
ten,  or  some  other  disinfectant,  should  be  sprinkled  freely  over 
the  bed  and  on  the  floor.  Cloths  wet  in  the  solution  should 
also  be  suspended  in  the  room.  In  severe  cases,  especially  after 
the  first  week,  the  patient  must  not  under  any  circumstances  be 
allowed -to  assume  the  erect  posture,  as  fatal  syncope  might  re- 
sult   To  prevent  hypostatic  pneumonia  the  nurse  should  be 


— tuiiMW 


miiiii 


IIVdIKNIO   AND   DIKTKTK;  THKaTMENT. 


MO") 


f/. ),  or  coiitotl  \vl»itt> 

il  w(it<'r{^»r«..  jtlion.). 

I.).     Supi)i»'H«i"n  t»f 

r»>t«'clu»)  oil  tho 

IcHtloHH  hlot'p,  with 
>  paiiiH  Ix^nin  in  tli« 
rtpinc  Tho  «^ynH  «»•- 
10  fact'  irt  tluwhod,  «»r 
ic.ii.  Tho  t(t>in\io  in 
iwn  tho  center.  Tho 
e  hoivrthoatH  vupidly 
on  of  the  choHt  with 
iniition.      Hiccough. 

Brain  exhnuation. 
I  {InjoH.).  Constftnt 
liirphoU)gin.  Subsul- 
,  (ici<l).     Involuntary 

\TMENT. 

vinitilaied,  for  in  ty- 

;hnn  ventilation.     AU 

iboiit  the  pntieni,  day 

will  always  be  better 

erythingthatis  liable 
>e  removed  from  the 
I  aH  Boon  as  the  fever 
.  be  prohibited.    All 
led.     Throughout  the 
I  the  strictest  cleanli- 
es  diluted  one  part  to 
sprinkled  freely  over 
the  solution  should 
cases,  especially  after 
any  circumstances  be 
atal  syncope  might  re- 
the  nurse  should  be 


instruotod  to  turn  tho  patiout  upon  on*'  si(h>  or  the  othrr  f>\t<ry 
few  hours. 

Tho  f/i>7  PonsimtH  principally  of  milk,  wIiumj  may  bo  ndiriiitis- 
tored  ico  cold  if  tIcHirod.  Aftor  throo  or  four  dfty^*.  to  support 
strongth,  boof  ton,  mutton  broth,  light  H(mpH,  milk  puii<-h.  or  yolks 
of  oggH  boaton  up  in  milk,  may  bo  alternatod  witli  milk.  Tlx^ 
patient  should  bo  fed-  not  ovor-fod — as  often  as  tnory  two  hours 
during  tho  day,  and  ovory  throe  hours  during  tlio  night,  ('xcopt 
when  quietly  sleeping.  Water  may  bo  adniinintorod  without 
stint.  When  food  is  obstinately  refused  or  cannot  bo  swallowod, 
life  may  bo  sustained  by  {Mmring  li(|uid  nourishment  into  tiio 
stomach,  by  moans  of  a  long  tube  passed  through  tho  nose,  or  by 
rectal  alimontaticm.  Tho  hypodermatic  method  of  administoring 
remedies  (p,  98)  will  alio  bo  of  service  in  such  cases. 

8pongin<i  the  Ixidy  every  night  with  warm  whisky  and  water 
is  not  only  grateful  to  tho  patient,  but  is  also  useful  as  a  sanitary 
m^sure. 

Concerning  ba//(s,  which  are  deemed  advisable  unless  adynamia 
is  present,  Loomis,  who  has  had  large  experience  with  typhus  in 
this  country,  writes:  "  As  soon  as  the  temperature  of  tho  patient 
rises  to  104"  Fahr.  he  must  be  placed  in  a  bath,  the  temperature 
of  which  is  about  ten  degrees  below  that  of  the  patient;  grad- 
ually, by  the  addition  of  ice  or  ice- water,  bring  the  temperature 
of  the  bath  down  to  68"  Fahr.  or  70'  Fahr.  The  patient  must 
be  kept  in  the  bath  until  his  temperature  falls  to  101°  Fahr.  or 
102^  Fahr.,  then  taken  out,  quickly  dried  and  placed  in  bed.  For 
some  time  after  the  removal  from  the  bath,  the  axillary  temper- 
ature will  continue  to  fall,  as  the  trunk  parts  with  heat  to  the 
extremities.  As  soon  as  the  tempenitura  rises  again  to  104° 
Fahr.  the  patient  must  receive  another  bath.  If  the  patient  is 
Bufifering  with  intense  pain  in  the  head,  or  is  actively  delirious 
during  the  bath,  ice-bags  may  often  be  applied  to  the  head  with 
benefit 

"  As  soon  as  you  have  passed  the  first  week  of  the  disease, 
having  kept  the  patient's  temperature  below  103°  Fahr.,  usually 
it  will  not  be  necessary  or  advisable  to  continue  the  baths." 

The  constipation  of  typhus  may  be  relieved  by  the  adminis- 
tration of  enemata  of  strong,  warm  soap  suds  or  of  thin  gruel. 

Stimulants  are  very  generally  required  in  typhus  fever,  after 
the  fourth  day.    They  are  seldom  needed  before  the  appearance 


■■  <c 


in 


■  Ifrni'im, 


30G 


LECTURES  ON   FEVERS. 


of  the  eruption,  and  are  most  useful  in  the  second  week,  espe- 
cially at  the  approach  of  the  crisis.  Tlu-y  should  be  given  in 
cases  of  great  prostration  with  low  muttering  delirium  and  a 
tsndency  to  coma,  and  continued  for  several  days,  especially  if 
under  their  administration,  the  patient  becom-^s  stronger  and 
more  rational.  A  iiopious,  dark  eruption  with  coldness  of  the 
extremities,  calls  for  stimulants;  while  active  delirium,  Lead- 
ache,  scanty  urination,  and  intense  Lett  of  the  cutaneous  surface 
render  their  administration  inadvisable.  As  in  other  fevers,  the 
first  sound  of  the  heart  and  the  character  of  the  pulse  are  the 
best  indications. 

No  positive  instructions  can  be  given  as  regards  the  amount  of 
stimulation  required  in  each  case.  The  quantity  necessary  va- 
ries ft'om  one  ounce  to  ten  or  twelve  ounces  of  brandy  or  whisky, 
daily  administered  in  tablespoonf  ul  doses.  It  is  rarely  neces- 
sary to  give  more  than  eight  ounces  in  twenty-four  hours.  Brandy, 
whisky  and  champagne  are  the  best  stimulants.  Where  stQ^dy 
stimulation  is  called  for,  a  tablespoonful  of  brandy  or  whisky 
punch  (prepared  by  putting  two  tablespoonf uls  of  brandy  or 
whisky  into  a  tumblerful  of  milk;  may  be  given  alternately  with 
two  tablespoonf  uls  of  beef  essence  (p.  190)  or  of  beef  tea  (p.  193), 
every  two  hours. 

Ale  or  porter  may  be  allowed,  if  desired,  during  convalescence, 
in  preference  to  other  stimulants. 

Premature  exposure,  over-exertion  and  excessive  eating  should 
be  carefully  guarded  against 


EVER8. 

il  in  the  second  week,  espe- 
Tlit-y  Bhonld  be  given  in 
muttering  delirium  and  a 
r  several  days,  especially  if 
;ient  becom'is  stronger  and 
uption  with  coldness  of  the 
hile  active  delirium,  head- 
eat  of  the  cutaneous  surface 
ble.  As  in  other  fevers,  the 
laracter  of  the  pulse  are  the 

ren  as  regards  the  amount  of 
The  quantity  necessary  va- 
ouflces  of  brandy  or  whisky, 
1  doses.  It  is  rarely  neces- 
.  twenty-four  hours.  Brandy, 
b  stimulants.  Where  stQpdy 
•onful  of  brandy  or  whisky 
tablespoonfuls  of  brandy  or 
lay  be  given  alternately  with 
p.  190)  or  of  beef  tea  (p.  193), 

ssired,  during  convalescence, 

a  and  excessive  eating  should 


LECTUEE  XX. 

Relapsing  Fever, 

I  shall  speak  to-day  concerning  Relapsing  fever,  the  second  in 
our  list  of  contagious  fevers. 

Definition.— It  may  be  defined  as  an  acute,  peculiar,  conta- 
gious fever,  occurring  in  the  form  of  an  epidemic,  chiefly  met 
with  during  seasons  of  scarcity  and  famine,  due  to  the  action  of 
a  specific  poison,  supposed  to  be  a  spirillar  onjanism.   It  is  char- 
acterized by  a  succession  of  febrile  and  non-febrile  events,  and 
consists  of:    1.  The  primary  paroxysm,  marked  by  quick  onset, 
commonly  at  sunset,  with  or  without  chills  or  rigor;  frontal  head- 
ache, arthritic  and  muscular  pains;  a  coated  tongue,  thirst,  ano- 
rexia and  constipation;  tenderness  over  the  liver  and  spleen; 
high-colored  urine;  high  and  persistent  pyrexia;  a  rapid  but  weak 
pulse ;  occasionally  delirium ;  and  a  typical  crisis  on  the  fifth,  sixth 
or  seventh  day,  almost  invariably  attended  with  copious  perspir- 
ation.  2.  An  infermisston  when  the  patient,  though  extremely  de- 
bilitated, feels  perfectly  well,  and  which,  when  a  relapse  super- 
venes, comes  to  an  end  in  seven  days.     3.  A  first  relapse  which  is 
usually  ushered  in  at  noon,  with  or  without  a  distinct  chill;  runs 
a  course  similar  to  that  of  the  attack  of  invasion;  and  terminates 
by  an  abrupt  crisis  on  or  about  the  fifth  day.  Convalescence,  which 
is  generally  rapid,  usually  takes  place  upon  the  termination  of  the 
first  relapse;  occasionally  a  second,  and  still  more  rarely  a  third  or 
fourth  relapse  occurs.    A  fatal  result  is  infrequent,  but  may 
happen  in  consequence  of  sudden  syncope,  hemorrhage,  or  from 
suppression  of  urine  and  coma.     No  constant  specific  lesions  are 
found  upon  examination  after  death.    One  attack  affords  no  im- 

(307) 


mrntsti^,^ 


308 


LECTURES  ON   FEVERS, 


rnunity  from  subsequent  attacks.  The  duration  varies  from 
fourteen  to  twenty-six,  or  thirty-nine  days.  The  period  of  incu- 
bation varies  from  five  to  seven  days. 

Synonyms. — It  is  otherwise  known  as  spirillum  fever,  and  has 
been  described  by  different  writers  as  famine  fever,  five  day  fe- 
ver, seven  day  fever,  short  fever,  bilious  relapsing  fever,  hunger- 
pest,  Gujerath  sickness,  contagious  or  jaundice  fever,  Silesian 
fever  and  Bombay  fever.  ' 

History. — Kelapsing  fever  is  by  no  means  a  new  disease,  as 
there  are  numerous  evidences  of  its  having  existed  from  a  very 
early  period.  Spittal  referring  to  its  antiquity,  states  that  the 
epidemic  described  by  Hippocrates  as  having  occurred  more 
than  twenty  centuries  ago,  in  the  island  of  Thasos,  in  the  iEgean 
sea,  off  the  coast  of  Eoumelia,  must  have  been  relapsing  fever. 
In  modern  times  the  disease  has  prevailed  at  different  epochs, 
and  was  first  clearly  described  by  Dr.  John  Kutty,  of  Dublin, 
in  1739. 

Wide-spread  epidemics  of  relapsing  fever  and  typhus  fever 
prevailed  in  Ireland  and  Scotland  in  1817-19. 

Following  a  commercial  crisis,  they  again  broke  out  in  Ireland, 
in  the  summer  of  1826,  and  extended  to  England.  For  sixteen 
years  thereafter,  relapsing  fever  remained  unobserved. 

An  outbreak  occurred  in  1842,  starting  first  on  the  east  coast 
of  the  county  of  Fife,  and  extending  over  Scotland  and  England. 

The  first  epidemic  occurred  in  this  country— where  relapsing 
fever  is  not  indigenous— in  1844,  and  was  directly  traceable  to 
the  landing  of  two  infected  Irish  female  emigrants  from  a  Liver- 
pool packet,  at  Philadelphia. 

Following  the  failure  of  the  potato  crop  in  1846,  an  extensive 
epidemic  started  in  Ireland,  and  extended  all  over  the  British 
Isles.  About  this  time  an  epidemic,  consisting  partly  of  relaps- 
ing fever  and  partly  of  typhus  fever,  prevailed  in  upper  Silesia. 

From  1847  to  1851  it  appeared  again  in  New  York  and  Buffalo, 
and  in  several  of  the  larger  Canadian  towns. 

During  the  summer  of  1855,  it  prevailed  among  the  British 
troops  in  the  Crimea. 

Following  the  liberation  of  the  serfs,  it  appeared  in  Russia, 
principally  among  the  poorest  and  most  destitute  classes;  firsts 


ETIOLOGY, 


309 


fttion  varies  from 
'he  period  of  iiicu- 

Jum  fever,  and  has 
fevei',  five  day  fe- 
ting fever,  hunger- 
ice  fever,  Silesian 

}  a  new  disease,  as 
ixisted  from  a  very 
ty,  states  that  the 
rig  occurred  more 
asos,  in  the  iEgean 
sn  relapsing  fever, 
t  different  epochs. 
Rutty,  of  Dublin, 

and  typhus  fever 

roke  out  in  Ireland, 

[land.     For  sixteen 

observed. 

st  on  the  east  coast 

tland  and  England. 

r — where  relapsing 
irectly  traceable  to 
rants  from  a  Liver- 

1 1846,  an  extensive 
ill  over  the  British 
ng  partly  of  relaps- 
ed in  upper  Silesia. 
IV  York  and  Buffalo, 

among  the  British 

ppeared  in  Bussia, 
stitute  classes;  first 


at  Odessa,  in  18G3,  and  then  at  St.  Petersburg,  in  18G4,  where  it 
has  prevailed  ever  since. 

In  18(57,  typhus  fever  and  relap.sing  fever  reappeared  in  Sile- 
siii,  and  extended  in  the  following  year  to  Germany. 

In  18G9-70  it  prevailed  to  a  considerable  extent  in  Philadel- 
phia, New  York  and  other  large  cities  of  this  country.  Like  the 
former  epidemic  it  was  directly  traceable  to  importation  through 
Irish  and  German  emigrants. 

In  the  latter  part  of  1872,  relapsing  fever  broke  out  in  Berlin, 
and  reappeared  in  1878  and  1880. 

It  prevailed  in  the  Bombay  Presidency,  and  in  Northern  and 
Western  India,  from  1877  to  1880. 

An  extensive  epidemic,  occurring  mostly  among  males,  i)re- 
vailed  at  Konigsberg,  in  ia79  and  1880. 

Nearly  all  the  epidemics  of  relapsing  fever  have  originated  in 
Ireland,  and  have  generally  been  associated  with  want  and  over- 
crowding. Central  foci  are  supposed  to  exist  in  the  Asiatic 
provinces  between  Russia  and  India. 

Etiology.— The  causes  of  relapsing  or  spirillum  fever,  are  of 
two  kinds,  viz.,  predisposing  and  exciting. 

1.  The  Predisposing  Causes.— Age  exerts  a  slight  influence. 
Nearly  one-third  of  all  cases  occur  in  early  life,  and  about  one- 
fourth  occur  between  the  ages  of  twenty  and  thirty  years.  After 
fifty  years  of  age  the  disease  is  rarely  obser^-ed. 

Occupation,  except  as  it  involves  actual  exposure,  as  is  the  case 
with  hospital  internes,  physicians,  nurses,  etc.,  does  not  predis- 
pose to  relapsing  fever. 

Destitution  and  bodily  fatigue  play  the  most  important  part 
among  the  predisposing  causes  of  the  fever.  The  connection  of 
spirUlar  infection  with  individual  want  is  very  marked.  Failure 
of  crops,  or  scanty  food  necessi<  ated  by  hard  times,  has  preceded 
almost  every  epidemic.  Occasionally  the  disease  has  developed 
and  spread  among  those  who  were  well-to-do,  and  were  well  fed. 
But,  as  a  rule,  no  great  epidemic  has  ever  arisen  or  spread  to 
any  considerable  extent  among  a  prosperous  and  well-fed  people. 

Exposure  to  heat  or  wet,  with  or  without  excessive  physical 
exertion,  has  been  observed  to  have  a  special  predisposing  effect 

Over-croicding  exerts  a  powerful  predisposing  influence.  In- 
fected localities  are  usually  those  limited  districts  where  pauper 


310 


LECTURES  ON  FEVERS. 


emigrants  congregate,   and  where  excessive  over-crowding  of 
apartments  or  of  houses  is  the  rule. 

'2.  The  ExcititKj  Cause. — Since  the  discovery  by  Otto  Ober- 
meier,  in  18(58,  of  the  constant  presence  of  certain  thin,  thread- 
like, spiral  fungi — spirochceii — in  the  blood  of  relapsing  fever 
patients,  the  parasitic  nature  of  the  contagion  and  tlie  possibil- 
ity of  the  existence  of  pathogenic  bacteria  have  become  almost 
positively  established.  These  spiral  filaments  (tig.  6)  named  by 
Cohn,  spirillum  Obcrmeieri,  in  honor  of  their  discoverer,  are  ex- 
ceedingly slender,  seldom  measuring  more  than  0.15  to  0.2  mm. 
in  length,  and  0.001  mm.  in  diameter.  In  them,  we,  in  all  prob- 
ability, have  the  infecting  principle  of  relapsing  fever,  which 
admits  of  being  conveyed  from  the  sick  to  the  healthy,  and  is 
capable,  under  favorable  conditions,  of  undergoing  development 
and  indefinite  reproduction.  And  yet,  notwithstanding  it  is  a 
generally  accepted  belief  that  the  spirillum  is  the  cause,  and  not 
simply  an  accompaniment  of  the  disease,  our  present  knowledge 
would  not  justify  us  in  declaring  any  given  case,  not  one  of  re- 
lapsing fever,  because  the  fungal  mycelia  are  not  found  during 
the  stage  of  pyrexia. 

The  question  whether  or  not  the  spirillum  alone  and  per  se 
produces  the  fever,  cannot  be  definitely  answered  until  its  pa- 
thogenic power  after  cultivation,  us  well  as  after  simple  isolation^ 
has  been  tested.  Drs.  Koch  and  Vandyke  Carter  have  sacceeded 
in  producing  relapsing  fever  in  monkeys,  by  inoculation  with  fresh 
spirillar  blood,  but  failed  to  produce  infection  with  either  non- 
spirillar  or  desiccated  blood.  They  also  succeeded  in  their  cul- 
ture experiments  with  infected  serum,  alone  or  after  dilution 
with  aqueous  humor,  outside  of  the  human  body,  but  found  that 
the  spirillum  does  not  grow  as  freely  as  does  the  bacillus  anthrr- 
cis.  They  have  not  as  yet  succeeded  in  producing  the  fever  by 
inoculation  with  the  cultivated  spirillum,  but  their  success  in 
producing  charbon  or  splenic  fever,  with  the  cultivated  bacillua 
anthracis  proves  that  diseases  can  be  so  produced,  and  destroys 
the  tJieory,  held  by  a  few,  that  septic  poisoning  alone  is  the  causfr 
of  pyrexia. 

True  to  its  plant  life,  it  is  probable  that  the  spirillum  observes 
that  periodical  order  of  growth  which  belongs  to  the  vegetable 
kingdom,  and  as  a  natural  inference  the  periodic  recurrence  of 
fever,  must  be  intimately  associated  with  corresponding  growth- 


ETIOLOGY. 


311 


ive  over-crowding  of 

icovery  by  Otto  Ober- 
certain  thin,  tliread- 
od  of  relapsing  fever 
gion  and  the  possibiU 
a  have  become  almost 
ents  (fig.  6)  named  by 
leir  discoverer,  are  ex- 
B  than  0.15  to  0.2  mm. 
them,  we,  in  all  prnb- 
ilapsing  fever,  which 
to  the  healthy,  and  is 
lergoing  development 
lotwithstanding  it  is  a 
1  is  the  cause,  and  not 
lur  present  knowledge 
;n  case,  not  one  of  re- 
are  not  found  during 

urn  alone  and  per  se 
mswered  until  its  pa- 
after  simple  isolation,, 
barter  have  succeeded 
inoculation  with  fresh 
ction  with  either  non- 
ucceeded  in  their  cul- 
one  or  after  dilution 
,  body,  but  found  that 
isthe  bacillus  anthrr- 
oducing  the  fever  by 
but  their  success  in 
le  cultivated  bacillus 
oduced,  and  destroys 
ing  alone  is  the  cause 

;he  spirillum  observes 
jngs  to  the  vegetable 
eriodic  recurrence  of 
orresponding  growth- 


states  of  the  parasitic  organism.     The  mamtenance  of  fo^e     s 
strictly  commensurate  with  sustained  parasiic  growth;  and  the 
sudden  termination  of  fever  is  unquestionably  re  ated  to  cessa- 
tion of  parasitic  growth.     Each  apyretic  interval  is  strictly   he 
incubation  period  of  the  following  febrile  event.     8o«.e  of    ho 
fHtal  and  more  serious  results  of  spviHar  infection  are  referable 
to  the  premature  growth  of  spiroch«eti  in  the  blood,  causing  in- 
creased liability  to  obstructions  of  the  circulation.     The  death 
of  the  parasitic  organisms  is  supposed  to  depend  upon  the  de- 
gree  of  consistency  of  the  blood.     Spirillar  filaments  have  been 
detected  in  hemorrhagic  effusions  and  in  th^  menses,  but  have 
not  as  yet  been  found  in  the  saliva,  sweat  or  urine. 

Direct  importation  is,  at  least  in  this  country,  the  probable 
method  of  introduction  of  relapsing  fever.  The  apparently  in- 
dependent  origin  of  some  epidemics  may  be  explained  by  con- 
sidering that  with  a  return  of  the  conditions  adapted  to  their 
growth. the  germs  or  "lasting  spores"  produced  during  previous 
illness,  and  remaining  for  a  long  time  dormant  in  the  earth  or 
building,  may  become  suddenly  revivified.  A  purely  spontaneous 
origin  is,  in  these  progressive  times,  absolutely  inadmissible. 

As  soon  as  relapsing  fever  has  appeared  in  any  locality,  it  not 
only  spreads  with  great  rapidity,  but  also  tends  to  form  pestilen- 
tial centers  for  itself,  in  districts  inhabited  by  the  poor.  The 
contagion  is  only  freely  communicable  by  the  .f  ^^Ph^J^'  ;« 
only  those  attendant  upon  the  sick,  or  who  visit  them  in  their 
close,  illy-ventilated  quarters,  or  live  in  adjoimng  apartments  or 
dweUings,  are  liable  to  take  the  fever.  The  probable  channels 
of  infection  are,  the  breath  and  the  cutaneous  transpiration  of 
the  sick.  Impure  drinking  water  is  believed  by  some  to  be  an 
important  carrier  of  the  infecting  principle. 

The  role  of  fomites  has  not  as  yet  been  clearly  ascertained. 
In  some  epidemics,  especially  in  this  country,  the  laundry  wo- 
men  in  hospitals  were  never  affected  by  the  fever,  while  in  others, 
particularly  in  Ireland,  they  contracted  the  disease  without  di- 
rect  contact  with  the  sick.  Exceptionally  the  disease  has  been 
transported  to  a  distance  by  infected  clothing.  Sleeping  on 
empty  ward-cots,  previously  occupied  by  persons  sick  with  re- 
lapsing  fever,  has  frequently  led  to  the  illness. 
By  the  inoculation  of  fresh  febrile  blood,  on  healthy  men,  the 


If 

i 


mism 


'HpHMUj'li.'iiriiWi  iiiiTt 


m 


LECTURES   ON   FEVERS. 


incubation  poriod  has  been  ascertained  to  be  not  less  tlian  five, 
nor  more  than  eight  days. 

One  attack  affords  no  immunity  from  subsequent  attacks.  In 
Ireland,  Itussia,  India  and  Egypt,  the  social  conditions  and  rela- 
tions of  the  pauper  population  are  such  as  to  render  the  disease 
practically  endemic  within  certain  areas. 

From  this  brief  review  o?  the  etiology  of  relapsing  fever,  we 
are  led  to  the  following  conclusions: 

1.  That  it  is  due  to  a  specific  poison,  probably  the  spirillum 
Obernieieri. 

2.  That  the  poison  is  communicated  from  the  sick  to  the 
healthy,  solely  by  actual  contact  with  tho  personal  exhalations 
of  the  patient. 

3.  That  the  disease  is  communicable  during  its  successive 
febrile  manifestations,  and  also  for  a  short  time  both  preceding 
and  following  the  earliest  of  these. 

4.  That,  while  famine,  over-crowding  and  bad  ventilation  fa- 
vor its  spread  and  increase  its  severity,  they  never  originate  it. 

5.  That  the  poison  passes  into  the  system  mainly  through  the 
respired  air. 

6.  That  a  prompt  re-infeotion  is  possible,  no  immunity  being 
conferred  by  a  first  attack. 

Forms.— Relapsing  fever  may  be  arranged,  according  as  the 
■  fever  does  or  does  not  return,  into  two  main  forms: 

1.  The  Abortive  Form,  characterized  by  a  single  febrile  attack 
— common  in  the  lower  animals,  but  uncommon  in  man. 

2.  The  Recurrent  or  Ordinary  Form,  with  one  relapse— most 
frequently  seen;  with  two  relapses— less  frequent;  with  three 
relapses— Tare;  with  four  relapses — very  rare. 

Clinical  History.— The  clinical  history  of  the  ordinary  form, 
embraces  a  description  of  the  invasion  attack  or  primary  par- 
oxysm, the  first  non-febrile  interval  or  stage  of  intermission,  the 
second  attack  or  relapse,  and  convalescence. 

The  Primary  Paroxysm.— Frodromea  are  seldom  recognized, 
HS  the  onset  of  the  disease  is  usually  abrupt.  Commonly  about 
sunset  the  patient  is  seized  with  a  high  fever,  ushered  in  by  a 
severe  rigor  or  by  a  distinct  chill.  Accompanying  the  chill  there 
are  severe  headache  (usually  frontal),  pains  in  the  spine  and 
limbs,  nausea  and,  not  infrequently,  greenish  vomiting  with  a 


1... 


"^saasa: 


CLINICAL  HI8T0RV. 


313 


lot  less  tlian  five, 

leut  attacks.  lu 
ditious  and  rela- 
>nder  the  disease 

apsing  fever,  we 

ly  tlie  spirillum 

the  sick  to  the 
jnal  exhalations 

g  its  successive 
both  preceding 

d  ventilation  fa- 
ver  originate  it. 
inly  through  the 

immunity  being 

according  as  the 

ms: 

jle  febrile  attack 

in  man. 

e  relapse — most 

lent;  with  three 

3  ordinary  form, 
or  primary  par- 
ntermission,  the 

lom  recognized, 
Jommonly  about 
ushered  in  by  a 
g  the  chill  there 
L  the  spine  and 
vomiting  with  a 


sense  of  weakness  and  indisposition  iov  exertion.  The  temper- 
ature rises  rnpidly,  and  mny  reach  104"  Fahr.  in  the  morning 
and  105°  Fahr.  in  the  afternoon  of  the  first  day.  During  the 
two  or  three  days  following  there  is  but  little  variation,  the  acme 
being  frequently  reached  during  the  first  twenty-four  hours. 
The  pulse  is  soft  and  compressible;  like  the  temperature  it  in- 
creases rapidly,  and  may  vary  from  110  or  120  to  140  or  even  160 
per  minute  within  the  first  twenty-four  hours.  The  eyes  be- 
come injected  early;  the  tongue  isAvhito  and  moist,  occasionally 
if  there  is  a  typhoid  tendency  it  becomes  dry.  The  bowels  are 
constii)ated;  thirst  is  considerable. 

As  the  disease  progresses,  the  pains  in  the  back  and  extremi- 
ties increase  in  intensity,  and  are  stabbing  and  lancinating  in 
character.  They  extend  to  all  parts  of  the  body,  but  are  most 
severe  in  the  calves  of  the  legs.  Sleeplessness,  as  a  result  of 
the  muscular  pain  is  a  frequent  and  distressing  symptom.  The 
mind  usually  remains  undisturbed;  occasionally  active  delirium 
occurs.  The  liver  and  spleen  become  large  and  tender,  after  the 
second  day,  and  there  is  more  or  less  delirium.  The  urine  is 
scanty,  shows  a  sp.  gr.  of  1015  to  1017,  is  acid  in  reaction,  de- 
ficient  in  chlorides,  and  contains  no  albumen;  when  jaundice  is 
present,  it  contains  bile  pigment. 

In  the  evening  or  during  the  night  of  the  sixth  or  seventh  day, 
after  a  brief  augmentation  of  all  the  symi)toms,  a  remission  sud- 
denly occurs,  attended  by  a  profuse  perspiration.  The  temper- 
ature falls  5°,  7°  or  even  10,  so  that  in  the  morning  the  body- 
heat  may  be  below  the  normal  standard.  The  pulse  declines, 
but  becomes  small  and  feeble.  The  number  of  respirations  also 
diminishes,  and  the  breathing  approaches  the  normal.  The 
headache,  the  muscle  pains  and  the  abdominal  uneasiness  sub- 
side.  The  tongue  speedily  cleans,  the  appetite  returns,  and  the 
jaundice  begins  to  fade.  The  spirilla  observed  in  the  blood 
during  the  paroxysm  have  now  disappeared.  And,  excepting  a 
sense  of  weakness,  the  patient,  who  but  yesterday  was  watched 
with  great  anxiety  and  alarm,  now  regards  himself  well.  He 
has,  however,  only  entered  upon  the  stage  of  intermission. 

The  Stage  of  Intermission.—Atter  about  a  week,  sometimes 
not  more  than  three  or  four  days  of  apparent  convalescence, 
usually  between  the  twelfth  and  twentieth  days  of  the  disease. 


3U 


LECTUnES  ON   FEVERS. 


the  i)ntient  is  taken  siiddenly  ill  with  all  the  phenomena  of  the 
primary  fover,  and  enters  upon  tho  staj^o  of  relapse. 

The  Stage  of  Erhij^se.— The  advent  of  tho  second  attack, 
which  usually  occurs  at  noon  or  in  the  night,  is  generally  attended 
by  chilliness  or  rigors.  The  pulse  increases  in  frequency,  but 
reaches  its  maximum  more  slowly  and  gradually  than  i;  the  pri- 
mary paroxysm;  occasionally  within  twelve  hours  it  reaches  140 
per  minuta  The  temperature  rapidly  rises  to  102^  Fahr.— ex- 
ceptionally to  10(5'  Fahr.  or  108°  Fahr.— on  the  first  day;  but 
soon  the  body-heat  is  higher  than  during  the  invasion  attack. 
The  common  symptoms  are  usually  those  of  the  primary  parox- 
ysm, only  they  are,  as  a  general  rule,  less  marked,  and  are  at- 
tended by  greater  debility.  As  in  the  primary  paroxysm,  the 
blood-spirillum  is  always  found  upon  microscopic  examination. 

The  duiatiou  of  the  relapse  varies  from  two  to  seven  days; 
usually  it  is  about  three  days.  Generally  the  second  crisis,  which 
occurs  oftenest  during  the  night,  is  as  abrupt  as  the  first,  being 
accomplished  in  a  few  hours,  and  accompanied  by  a  profuse  per- 
spiration. From  this  period  the  patient  usually  goes  on  to  com- 
plete recovery.  When  a  second  relapse  takes  place,  the  mean 
duration  of  this,  the  second  non-febrile  interval  or  intermission, 
is  ten  days,  and  that  of  the  relapse  is  two  or  three  days.  As 
many  as  three  or  four  relapses  may  occur,  but  generally  conva- 
lescence is  assured  after  the  second  non-febrile  interval. 

Convalescence.— ConvideBcence,  wliich  usually  lasts  as  long  as 
all  three  preceding  periods— three  to  six  weeks— is  marked  by 
a  condition  of  comparative  comfort.  But,  notwithstanding  the 
rapid  return  of  the  appetite,  the  emaciation,  the  loss  of  strength 
and  the  arthritic  and  muscular  pains  remain  for  some  time. 
Ansemic  murmurs,  frequently  noticed  during  the  course  of  the 
fever,  are  often  present  during  the  first  half  of  the  convalescing 
stage.  Post-febrile  oedema  of  the  feet  and  sometimes  of  the 
hands  and  face  is  not  infrequent. 

The  death-rate  in  relapsing  fever  seldom  exceeds  two  or  three 
per  cent.  Death  may  occur,  usually  at  the  close  of  the  relapse, 
from  the  intensity  of  the  fever,  and  the  consequent  exhaustion. 
In  a  limited  number  of  cases  it  may  take  place  in  consequence  of 
lung  complications,  sudden  heart-failure,  cerebral  hemorrhage, 
pyaemia  following  splenic  abscess,  or  from  urinary  suppression 
with  coma  and  convulsions. 


-  ^^ls£^a^slii^aii&^^B^UtMial>^ 


COMl'LU'ATIONS. 


315 


nomena  of  the 
ise. 

Becond  attack, 
erally  attended 
freqiienc}',  but 
lian  i;  the  pri- 
i  it  reaches  140 
02"  Fahr.— ex- 
lirst  day;  but 
ivasion  attack. 
)rimary  parox- 
k1,  and  are  at- 
paroxysm,  the 
t!  examination, 
to  seven  days; 
id  crisis,  which 
the  first,  being 
a  profuse  per- 
oes  on  to  com- 
lace,  the  mean 
r  intermission, 
ree  days.  As 
snerally  conva- 
terval. 

osts  as  long  as 
-is  marked  by 
hstanding  the 
»8s  of  strength 
or  some  time. 
I  course  of  the 
e  convalescing 
letimes  of  the 

Is  two  or  three 
if  the  relapse, 
at  exhaustion, 
onsequence  of 
I  hemorrhage, 
y  suppression 


'T*fcn  a,lU.ps.  and  death  from  heart-failure  may  occur  a,  a 

instances  abscess  accompanied  by  pyaimic  eyuv 
4„a».a  not  infrequently  occurs  as  a  seqnel. 

„„.t.on  -The  a---' -rr  f:^  "^^^ 

ANALYSIS  OF  CHART. 

mi.    v«„,«««  «lvstftm  -Vertiqo  occurs  as  an  early  symptom, 
J  irmTeT^efs'm'Lw  durin'g  ihe  iirst  and  third  stages  of 

*yX.c  is  the  commonest  of  a»  '^^^,J\^^fl 
ent   They  commonly  appear  with  the  lever,  augi 


:» 


■31G 


LECTUREH  ON  FEVEns. 
CHART  Xlll.—Hrlapsing  Frrcr. 


Nut  II  it: 


Etloloity: 


Epidoinli 


Contntiloxi' 


Initial  wympiom 


StiiBes; 


Diiriitlon. 


The  Splrilluiii  OlicrmcU'rI. 


Knininiv 


I'l'lin'ryl'iiroxyKiii 


Chlllliii'HsorrlifoiK. 

lMtl'Illli«- 


Mlon. 


KcUipRP 


Blx  to  seven  duyd 


''''"■"'V"|Tw..t..Hoveiul«yM 
seven  ilny«| 


t;innneou«       1    Kli»t  <liy  then 
Burfuei':         I  lUDlst. 


Nervous  Hygteni; 


'IVmpenUuro; 


PuUo; 


VertiRO.  liirtoiunlii 
Ifroiitnl  heft'laelie, 
Mumuliiipitlns.^ 

Ulse«  iiiplilly 
104"  or  Kfi-'Utdny 


MolHl. 


110"  to  UK)" 
Kiill  anil  Ireijuent. 


Tontfuo: 


Howcls : 


Stoinacb : 


Dry  mill  Uot. 


CoiivnleNeenee. 


'I'lireetoHlx  weekK 


lliinliiihe.  MiiK- 
iiiliupiilnH.  Oreiil 
(lel)llity. 


Debility.     Museii- 
liir  wenkiiesH. 


Whitoor  yellowish 
White  f'.ir.  Moist. 


Congtlpnteil. 


'I'hirst,    NiiUBeii. 

(Jreenish  voniit- 

liijf     Kpi(iii8tric 

lenderness. 


Mvor: 


Spleen ; 


Knlnriretl. 
Jiiundloc. 


Enlarijed. 


Urine: 


mood: 


Spirillum  present 


Defervesceneo. 


Complleations: 


Soiiiity.    Dark. 
Lowsp  Ki" 


Itiipid  and  eritleni 
on  tith  or  Tth  day. 


2   o 


■r. 

* 

O 
K 


Normal 


110  to  MO, 

Soft.      ConiprcBS- 

llile. 


Ulnen  rapidly. 
10!!"  to  lO'*". 


Oecnslonnlly 
deH<|unmatlon. 


VoinilinK 

Eplifastrle  louder- 

neBB. 


Furrt^d. 


Constipated. 


Enlnrifed. 
Juundlee. 


Normal. 


Slow 
Anivmu'  Mur- 
iniiri*. 

Clean  and  inomt 


Normal. 


Normal  appetite. 


Enlai'iJreil. 
Abseess. 


Scanty.    Dark. 

Slltfrbtiy  albumin 

oils. 


Spirillum 
absent. 


Attained. 


Spirillum  present. 


Normal. 

Ueliirns  to 
Normal. 

Norm  II  I. 


Spirillum  absent. 


Ilapid  and  critical 
on  I5lh  to  2.5th  day. 


Attained. 


I'roKnoslH : 


Itecnrrenees; 


Incubation: 


IJroncbills.                  Pneumonia.  Ophthalmia. 

Orebral  hemorrhage. Spicule  abseess. 


Favorable.         Mortality  is  from '-'  to  4  per  cent. 


.\  previous  attack  affords  no  immunity. 


Five  to  seven  days. 


THE   DIGESTIVE   TIIACT. 


:u7 


llUIIItll'. 


<"<>nvBleiic'cm-<', 


iTIiroctciHlx  wockH 


Ol-i'iisIiiiuiII)' 
(IcHijiinriiiitiiiii. 


Dcbllily.     MiiHi'ii 
liir  wi'iikiicHH. 


Noriiiiil. 


Slow 
Aiiirinii'  Mur- 
null's. 


CIciiii  mill  moist 


Xoi'iniii. 


Norm  III  Hppc'tlte. 


N'ormni. 


ItftiiniA  to 
Kormiil. 


N'orinal. 


Spirillum  iibscnt. 


Attained. 


phthaliiiiii, 
nbHfess. 


I'lT  cent. 


nlty. 


with  tho  olinnges  of  pyrexin,  and  HiibHule  iit  tlio  friHiH,  hxiving 
behiml  thorn  iimrked  luuHcuhir  weaknosB. 

DchHitji  CDines  on  oarly,  and  Ih  j^f  nerally  innrkod.  It  is  not  as 
severe  iis  in  typhus  fover,  but  Itoing  commonly  nssociatctl  with 
vertigo  and  arthritic  and  muscular  pains,  it  compels  patli>nts  to 
take  to  tlieir  beds.  The  ordinary  strength  is  not  regained  until 
convalescence  is  far  advanced. 

The  Digestive  Triiot.-  'A/V«/  is  a  constant  symptom  during 
the  fever.  It  is  usually  most  persistent  and  intense  iu  subjects 
of  low  type  of  fever. 

Appviiie  is  usually  wanting  during  the  fever.  At  tho  critical 
fall  it  often  returns  as  promi)tly  as  the  other  signs  of  relief.  An 
inordinate  appetite  has  been  noticed  in  some  cases,  near  the  end 
of  a  relapse,  just  before  probable  acme  and  sudden  death  by 
cerebral  liemorrhage. 

The  tongue,  as  a  rule,  undergoes  changes  corresponding  very 
closely  with  those  taking  place  upon  the  cutaneous  surface.  It 
is  dry  when  the  latter  is  dry,  and  moist  when  it  is  moist,  it  is 
generally  coated,  the  fur  being  either  -whitish,  yellowish-white 
or  brownish  in  color.  Occasionally  the  organ  is  flabby  and 
indented  at  its  edges  by  the  teeth.  Sometimes,  particularly  in 
young  persons,  the  papillte  are  enlarged,  and  the  tongue  presents 
a  "  strawberry  *'  aspect.  Pallor  of  the  tongue  usually  attends 
the  crisis. 

Nausea,  either  alone  or  preceding  and  alternating  with  vom- 
iting, is  a  not  infrequent  symptom. 

VomiUng  occurs  alike  in  the  abortive  and  ordinary  or  relapsing 
forms  of  the  fever.  It  is  generally  active  in  character  and  oc- 
curs of  tenest  in  young  men.  The  vomited  matters  consist  of  the 
ingesta,  and  of  glairy  mucus  and  diluted  bile  of  varied  hue. 
Specks  and  small  streaks  of  blood  are  sometimes  present  in  the 
ejected  mucus.  At  times,  when  the  stomach  is  unusually  irrita- 
ble, the  change  of  posture  will  induce  the  recurrence  of  vomiting. 

Epigastric  tenderness  is  a  common  symptom.  Notable  ten- 
derness exists,  in  some  cases,  over  the  liver  and  spleen. 

Splenic  enlargement  is  a  prominent  and  characteristic  symp- 
tom. It  occurs  early  and  may  often  be  detected  during  the  first 
twenty-four  hours.  It  steadily  increases  in  size  during  the  feb- 
rile period,  and  rapidly  diminishes  in  the  intermission  and  during 


' 


-■,** 


n 


k 


iim 


.ECTUUi:.s   ON    rKVKllM. 


C(.nv(iUiHC«>nce.  At  tho  oloso  of  tlut  piiiimry  imroxysiii  it  Iuih 
Httdiiicd  its  iiuixiimuu  nizo,  which  may  !>»>  two  or  tlu-oo  tiiii.-H  its 
natunil  Imlli.     It  can  lii.ui  h.i  f.-lt  tiirougii  tho  iiklominal  walla 

Tho  lircr  in  Hlij,'htly  (iiihiit^'cd, 

Jdiiwlici-  oc(Hirrt  in  a  Hniall  proportion  of  caHPs.  It  rar«>ly  ap. 
poars  bfforo  th«>  tliinl  or  fonrlii  day  of  (ho  invasion  attack,  dis- 
appears during  th(*  mtprniission,  and  reappears  diirinj  tiio 
relapse.    It  is  soldoni  persistent,  usually  vanishing  in  n  few  days. 

Onus/ i  pa  I  ion  may  ho  i)rosent  for  a  few  days  before  the  onset 
of  jnimary  fever.  Usually  tho  alvine  functions  remain  uiidis- 
turhed.  Intestinal  catarrh  sometimes  occabions  more  or  Ichb 
persistent  diarrhea.  " 

The  TemperutiiiT.  -In  well-marked  uncomj)licated  cases  tho 
course  of  tho  fevr  is  tyj)icnl  (tig.  KJ).  The  temperature  rise 
w  always  siuhlen  and  is  usually  connected  with  increasing  growth 
and  8j)ore  production  in  the  blood.  Often  during  the  initial 
chill  or  rigor  it  roaches  102  Fahr..  and  generally  within  twenty, 
four  hours  it  goes  up  to  lOi"^  Fahr.  or  IOC  Fahr.  Not  iufre- 
(luontly  it  attains  its  maximum  on  the  first  day.  Generally  the 
highest  tem])erature  is  observed  just  before  tho  crisis.  The  tern- 
perature  cur/e  is  irregularly  remittent,  being  interrupted  by  sol- 
itary peaks  of  exacerbation.  The  morning  and  evening  varia- 
tions  in  the  diurnal  curve,  range  from  a  few  tenths  to  one  or 
one  and  a  half  degrees. 

At  the  crisis  the  downfall  occurs  with  a  rapidity  that  is  char- 
acteristic. The  temperature  falls  from  4"  Fahr.  to  10°  Fahr.  in 
an  unbroken  line  within  twelve  hours.  For  one  or  two  days  the 
morning  temperature  may  even  be  sub-normal— 95°  Fahr  to  97° 
Fahr 

With  the  onset  of  the  relapse,  the  temperature  rise  is  again 
quite  sudden,  reaching  102 '  Fahr.  or  104  Fahr.  in  an  abrupt 
line  within  a  few  hours.  The  peaks  grow  daily  higher  and 
higher,  and  the  last  repr-  ^ents  the  maximum  temperature  of  the 
relapse,  which  is  somew.  higher  than  that  of  the  primary  nar- 
oxysm— 105"  Fahr.  to  101     Fahr. 

Defervescence  usually  succeeds  by  a  rapid  and  unbroken  fall 
pf  r  Fahr.  or  even  12^  Fahr.  in  twelve  hours—  a  fall  greater 
than  that  of  any  other  disease. 

The  Pulse.-The  pulse  rises  rapidly,  and  varies  from  90  to 


fWiir  \u\ttummamimum 


TKMI'I'.UATrilf,   llANlti;, 


mo 


P'lroxyHiu  it  linH 
|><>r  thi-oo  tim«'8  its 
I'  'ilKldiniiml  wiiIIh. 

[«•'«■     Jt  rnrvly  np- 
jv'iHit)!!  attack,  ,li„. 

f»i»iginnf(nvtlayH. 

J"iM  n.iiiain  mi.Iis- 
ions    iii,)i-o  or  J^hs 

iplicatod  caHes  the 
tt'iiipoiaturo  rise 
iiicri'aHiiij^  growth 
'ming  tlie  initiaj 
ly  witJiiii  twejjty. 
^'ilir.    Not  iiifre. 
'•      Generally  the 
^  crisis.    Thetem. 
•terrupted  bysGl. 
ill  evening  varia- 
tenths  to  one  or 

idity  that  is  char- 
r.  to  10"  FaJ,r.  in 
0  or  two  flays  the 
-95"  Pahr.  to  97° 

kure  rise  is  again 
hr.  in  an  abrupt 
aily  higJier  and 
operature  of  the 
ilie  primary  par- 

id  unbroken  fall 
—  a  fall  greater 

ries  from  90  to 


Ml, 

1     s 

1 1 1 1 

5      S 

Mil 

Mil 

MM      M  1  1  M  1  M 

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320 


LECTUUES   ON  FEVEU.S. 


120  or  liO  per  miimtc.  It  is  eight  or  ten  beats  faster  in  tlie 
tiveiiing  than  in  the  morning.  It  is  ofton  full  and  tense  during 
the  febrile  paroxysm,  but  becomes  soft  and  compressible  after 
the  crisis.  During  the  rapid  defervescence  following  the  crisis  it 
may  full  from  140  to  50  in  a  few  hours. 

The  cardiac  impulse  and  first  sound  are  weakened  after  the 
crisis,  but  gradually  regain  their  power  as  convalesijence  becomes 
established.  During  the  i)rimary  jmroxysm  and  the  relapse,  soft 
systolic  murmurs  are  not  infrequently  heard<  upon  auscultation, 
at  the  base  of  the  heart. 

The  Cutaneous  Surface. — In  both  the  primary  paroxysm  and 
the  relapse,  the  skin  l)ecome8  moist  shortly  before  the  tempera- 
ture declines.  The  critical  termination  of  the  relapse  is  often 
attended  with  sweat,  more  copious  than  in  an  intermittent  par- 
oxysm. In  most  cases  the  sweating  is  so  excessive  that  the 
clothes  and  even  the  bedding  become  saturated.  Partial  or 
nocturnal  sweating  is  not  uncommon  for  two  or  three  diiys  after 
the  crisis. 

Sndamina,  varying  in  size  from  a  pin  point  to  a  split  pea,  are 
observed  in  some  epidemics.  They  are  commonest  at  the  crisis; 
sometimes  they  appear  in  successive  crops.  A  branny  exuvium 
or  a  desquamation  of  the  cuticle  in  flakes  sometimes  occurs. 

The  Urine. — The  urine-changes  in  relapsing  fever  are  singu- 
larly slight.  At  or  near  the  acme,  the  urine  is  scanty,  acid,  and 
high-colored.  Though  clouded,  it  leaves  no  lateritious  deposit 
on  cooling,  such  as  is  found  in  other  febrile  diseases. 

Albumen  in  small  proportions  is  not  uncommon.  Blood  and 
tube-casts  are  rarely  observed.  When  jaundice  exists,  bile  pig- 
ments are  present  in  the  urine. 

Morbid  Aoatomy. — No  invariable  lesion  is  found  after  death 
from  relapsing  fever.  The  special  features  of  the  disease  are 
principally  cerebral  hemorrhage,  pneumonia,  collapse  of  the 
lungs,  enlargement  and  pallor  of  the  liver  and  kidneys,  enlarge- 
ment or  firmness  and  infarcts  of  the  spleen,  congestion  and  ex- 
travasations in  the  intestinal  walls. 

Emaciation  is  rarely  extreme. 

Cadaveric  rigidity  appears  early  and  is  long  continued. 

The  brain  presents  no  characteristic  changes.  Serous  effu- 
sion, usually  cleai*and  yellowish,  and  practically  limited  to  the 


VERS. 

or  ten  beats  faster  in  the 
Iten  full  and  tense  during 
soft  and  compressible  after 
jence  following  the  crisis  it 

s. 

and  are  weakened  after  the 
ir  as  convalescence  becomes 
Dxysm  and  the  relai)so,  soft 
y  hearcL  upon  auscultation, 

I  the  primary  paroxysm  and 
;hoi-tly  before  the  tempera- 
tion  of  the  relapse  is  often 
han  in  an  intermittent  par- 
ig  is  so  excessive  that  the 
jme  saturated.  Partial  or 
I  for  two  or  three  days  after 

pin  point  to  a  split  pea,  are 
ire  commonest  at  the  crisis; 
crops.     A  branny  exuvium 
(lakes  sometimes  occurs. 

in  relapsing  fever  are  singu- 
he  urine  is  scanty,  acid,  and 
eaves  no  lateritious  deposit 
'  febrile  diseases, 
not  uncommon.  Blood  and 
len  jaundice  exists,  bile  pig- 

e  lesion  is  found  after  death 
1  features  of  the  disease  are 
pneumonia,  collapse  of  the 
e  liver  and  kidneys,  enlarge- 
iie  spleen,  congestion  and  ex- 


and  is  long  continued. 

istic  changes.     Serous  effu- 

md  practically  limited  to  the 


MORBID  ANATOMY. 


321 


loose  sub-arachnoid  tissue  at  the  vertex  and  sides  of  the  brain 
is  sometimes  observed.  Marked  effusion  is  most  commonly  seen 
«t  the  close  of  the  febrile  paroxysm.  More  or  less  cop-ous  hem- 
orrhages in  the  arachnoid  and  sub-arachnoid  spaces,  et  p.cially 
over  the  upper  convexity  of  the  hemispheres  may  be  found. 
Fatty  degeneration  of  the  smaller  vessels  sometimes  attends  the 
cerebral  hemorrhage.  The  deeper  seated  substance  of  the  brain 
rarely  becomes  aflfected.  Heydenrich  and  Carter  have  noticed 
the  possible  formation  of  emboli  in  the  smaller  vessels  from  the 
clustering  and  aggregation  of  the  spirilla  into  compact  masses. 

Tlic  spleen  will  be  found  considerably  enlarged,  especially  if 
death  has  occurred  during  the  febrile  state.  The  capsule  is 
thickened,  smooth,  tense  and  slightly  clouded,  and  the  malpi- 
ghiari  tufts  are  more  prominent  than  normal.  After  the  crisis 
the  organ  will  be  found  to  be  diminished  in  size,  and  the  capsule 
■will  present  a  shriveled  appearance.  Wedge-shaped  infarc- 
tions, or  altered  portions  of  the  spleen-pulp,  are  occasionally 
met  with.  They  are  commonest  at  the  edges  of  the  organ.  Ex- 
ceptionally they  break  down  and  form  abscesses. 

The  liver  is  commonly  enlarged  and  of  a  yellowish-gray  hue. 
The  enlargement  may  be  due  to  cloudy  swelling  and  pigmentary 
or  fatty  transformation  of  the  gland  cells.  Congestion  is  often- 
est  noted  immediately  after  the  cessation  of  fever. 

The  kidneys  are  enlarged,  flabby,  friable  and  of  a  pale  yellow- 
ish color.  Congestion- of  the  mucous  membrane  of  the  pelvis, 
and  cloudy  swelling  of  the  renal  cells  are  frequently  seen. 

The  stomach  frequently  displays  small  spots  of  blood  extrava- 
sation upon  its  mucous  surface. 

The  intestines  present  no  changes  other  than  those  of  conges- 
tion, inflammation  or  hemorrhage,  affecting  the  ileum  and  lower 
-end  of  the  jejunum. 

The  heart,  in  a  large  proportion  of  cases,  shows  no  structural 
change.  In  some  instances  fine,  granular  infiltration  of  the  mus- 
cular fibres  has  been  observed.  Blood-clots  are  generally  present 
in  the  heart-cavity;  and  small  quantities  of  clear  serum  are  fre- 
quently found  in  the  pericardial  sac. 

The  liinys  frequently  display  the  changes  in  structure  incident 
to  the  occurrence  of  bronchitis  or  pneumonia  as  complications. 

The  Wood  of  relapsing  fever  patients  presents  a  number  of 
.striking  changes.     During  the  primary  paroxysm,  for  the  first 


322 


LECTUllES   ON   FEVERS. 


few  days  tho  plasma  is  often  clear,  later  on  it  becomes  clouded. 
The  white  blood-cells  are  increased  in  quantity,  and  the  red  discs 
frequently  present  a  bent  or  cupped,  shriveled  aspect.  Leuco- 
cytes increase  in  numbers  as  the  attack  progresses,  until  the 
acme  is  reached.  Large,  colorless  granule-cells  are  frequently 
observed  at  "^he  close  of  the  febrile  period.  Tliey  are  oftener 
found  in  the  relapse  than  in  the  primary  paroxysm.  Their  source 
is  supposed  to  be  from  the  spleen  and  lymphatic  system.  Fila- 
ments, {,'ranules,  or  short  rods  have  also  been  observed.  They 
have  been  noted  during  the  primary  paroxysm,  but  have  been 
oftenest  see  a  at  the  critical  defervescence.  Their  nature  and 
origin  is  unjcuown. 

Spirilla  or  spirochseti  are  commonly  present.  As  seen  in 
freshly  drawn  blood,  they  appear  as  colorless,  slender,  twisted 
filaments,  actually  moving  in  the  liquid  plasma,  until  coagulation 
begins,  when  they  seek  refuge  amongst  the  red  corpuscles.  The 
quiescent  filaments  have  a  length  of  from  two  to  six  times  the 
diameter  of  a  red  disc.  They  resemble  a  spiral  rod,  with  from 
four  to  ten  spiral  turns.  From  five  to  ten  spirilla  are  generally 
Tisible  in  the  field  of  the  microscope  at  one  time;  occasionally 
they  appear  in  swarms.  As  a  rule,  not  less  than  one  spirillum 
will  be  found  in  an  ordinary  specimen— one-fourth  of  a  drop  — 
of  infected  blood.  If  there  are  250,000  millions  of  red  discs  in 
the  human  body,  one  spirillum  to  one  thousand  discs  would  give 
an  aggregate  of  about  two  hundred  and  fifty  millions  of  blood- 
parasites. 

Spirilla  are  absent  during  the  early  stage  of  the  incubation 
period,  but  are  present  during  the  latter  part  of  it.  They  rapidly 
increase  with  the  advent  and  during  the  progress  of  the  fever. 
They  disappear,  as  a  rule,  rapidly,  with  the  cessation  of  the 
fever.  The  ordinary  duration  of  individual  spirillar  organisms 
has  not  been  ascertained.  The  length  of  visible  blood  infection 
varies  from  two  or  three  to  eight  or  ten  days. 

By  contact  with  the  sick,  or  by  inoculation  of  blood  containing 
these  spiral  organisms  or  their  germs,  relapsing  fever  may  be 
conveyed  to  new  or  old  subjects. 

Differential  Diagnosis.— The  diagnosis  of  relapsing  fever 
after  the  disease  has  ended  is  extremely  easy;  but  at  the  begin- 
ning of  an  epidemic,  during  the  primary  paroxysm,  it  is  often, 
attended  with  difficulty. 


I:- 


DIFFEKENTIAL  DIAGNOSIS. 


323 


|i  it  becomes  clouded. 
tity,  and  the  red  discs 
fled    aspect.     Leuco- 
progressRd,  until  the 
J-cells  are  frequently 
They  are  oftener 
Jxysra.    Their  source 
)hatic  system.     Fila- 
feen  observed.     They 
xysm,  but  have  been 
Their  nature  and 

-esent.     As  seen  in 
ess,  slender,  twisted 
ma,  until  coagulation 
red  corpuscles.    The 
two  to  six  times  the 
jiral  rod,  with  from 
pirilla  are  generally 
e  time;  occasionally 
i  than  one  spirillum 
^-fourth  of  a  drop- 
lions  of  red  discs  in 
and  discs  would  give 
iy  millions  of  blood- 

fe  of  the  incubation 
tofit.  They  rapidly 
ogress  of  the  fever, 
he  cessation  of  the 
spirillar  organisms 
ible  blood  infection 

of  blood  containing 
?sing  fever  may  be 

of  relapsing  fever 
';  but  at  the  begin- 
iroxysm,  it  is  often. 


The  distinctive  characters  are,  the  abruptness  of  iiivnsioii,  the 
unusual  rise  in  temperature,  the  prominence  of  severe  muscular 
pains  of  a  rheumatic  character,  tlie  occasional  occurrence  of 
jaundice  accompanied  by  more  or  less  tenderness  and  fullness  in 
the  hypochondriura,  the  critical  defervescence  about  the  fifth  or 
seventh  day,  and  the  almost  constant  occurrence  of  a  relapse  on 
the  twelfth  or  fourteenth  day. 

The  pathognomonic  test,  I  would  have  you  remember,  is  the 
presence  of  spirilla  in  the  blood  during  the  periods  of  invasion 
and  relapse.  Do  not  understand  me  as  saying  that  the  disease 
is  to  be  invariably  recognized  by  this  blood-test,  but  believe  me 
as  affirming  that  the  experiments  of  recent  investigators  dem- 
onstrate that  when  the  test  is  applicable  it  settles  for  good  a 
doubtful  diagnosis. 

To  demonstrate  tlys  spirilla  it  is  necessary  to  employ  nmgnify- 
ing  powers  of  not  less  than  500  diameters,  and  for  special  inves- 
tigation the  liigher  power  immersion-lenses  are  needed.  Carter 
recommends  that  a  minute  drop  of  fresh  blood  be  taken  from  the 
washed  finger  of  the  patient,  by  ])ricking  with  a  needle,  and 
placed  on  a  thin  glass  cover,  which  is  then  inverted  and  })ut  on 
the  slide  for  examination.  The  examination  is  best  conducted 
by  daylif.  lit.  In  cases  of  doubt  more  than  one  specimen  should 
be  examined.  Dried  specimens  are  not  as  serviceable  as  fresh 
ones. 

The  diseases  with  which  it  is  possible  to  confound  relapsing 
fever  are,  typhoid  fever,  typhus  fever,  cerebro-spinal  fever,  re- 
mittent fever,  yellow  fever,  dengue,  small -rtx  (previous  to  erup- 
tion) and  raeasles. 

The  chiof  points  of  contrast  between  relapsing  fever  and 
typhus,  typhoid  (p.  166)  and  cerebro-spinal  (pp.  166  and  286) 
fevers,  you  are  already  so  familiar  with  that  their  repetition  is 
unnecessaiy. 

Remittent  fever,  especially  when  tropical  or  sub-trojucal,  occa- 
sionally closely  resembles  relapsing  fever.  It  differs,  however, 
by  being  of  malarial  origin,  and  by  showing  pigment  granules 
and  the  bacillus  malarite  (p.  55)  instead  of  the  blood-spirillum. 

Yellow  fever  sometimes  closely  resembles  i  elapsing  fever. 
The  latter,  however,  is  always  propagated  by  contagion,  while 
the  former  is  not.     An  enlarged  spleen  is  the  rule  in  relapsing 


mmimmm 


LECTURES  ON  FEVEBS. 

,e,er,  and  th»  exception  in  ,ellow  fevsr.   In  »!!  C..S  an  ex^nin.- 

^^^^^^^^  -  -•>"-  -"■  '^  "' 

character  of  the  remissions.  „„mblance  to  relapsing 

SmOl-po.  presents  some  pomte  of  re«,mbl.    ^^.^  ^^P  ^^_^ 

fe,er  during  '^f^'^i^'XZ  ii^M^  "l  the  fever,  and 

mI^,  is  to  be  a'-B»-«:«J-:;,t"^al''imp. 
eruption,  by  the  course  of  the  fever,  ana  oy 
toms  of  the  premonitory  stage. 

Pr«g«o*.-The  prognosis  in  -1>P»»8 '"-^ '^^^l'  St 
death-™te  being  abont  three  per  cent  ^'P^'  '^  „, 

attends  the  primary  paroxysm  »*  the  toljelapse^  ^^^^ 

«o  i«,q5r»fttps  risk  from  complications, 
vescence  inaicaieB  riBu.  ii""'         t-  u,-,^  tmm  some 

„      Uydeatho^^s^ot^^^^^^^^^^ 

z.t™t:ti„r'maro:r'.-p-'---™-»-^^--''"'^ 

"oTatli^-^^-i--"^''---'''^-       ^        ^ 

famine  are  strong  predisposing  «  "^'^t'oatCk  of  an 

^r  ot.an '"'-'^  ?-:^f;,£^„3:l:  f^^,  and  more 
epidemic,  be  provided  '*  3^'  «„  n,easnres  shonld 

spacious  apartments  7™*  f™""?  ^„  .^^^a  be  remedied,  all 
be  early  applied.  All  defective  '1™"''^^  Srters  used  for  drink- 
filth  and  garbage  »l'o»W  be  removed^  AU  «J^J^J^^„„,  „a 
ing purposesmnst be  tailed befo^jed     Adequ.^^^  ^^_^^^^ 

personal  hygiene  ^"^  b^°SeT.^  „„a  de.ns«l.  A  camp 
Abundant  ventilation,  and  ^'P^™"^  .5°°°  °^^,  „d  in  local- 
hospital  is  a  eanitary  necessity. 


„ iii.riiir"T'  rvitii   wWii'  r jTrmaiiHriii  iifi  i 


1^ 


PRINCIPJIL  REMEDIES. 


leases  an  examina- 

iption  and  by  the 

lance  to  relapsing 
the  third  day,  the 
of  the  fever,  and 
f  the  hair, 
sing  fever  by  the 
lie  catarrhal  symp- 

ver  is  favorable,  the 
p-eatest  risk  of  life 
jlapse.  Absence  of 
r  paroxysm  should 
le  liver  and  spleen 
pneumonia  or  dys- 
post-critical  defer- 

ase,  but  from  some 
sudden  syncope.  A 
i,  uraemia,  dysentery 

ifection. 

wding,  poverty  and 
relapsing  fever,  the 
the  outbreak  of  an 
ome  food,  and  more 
bive  measures  should 
)uld  be  remedied,  all 
'aters  used  for  drink- 
adequate  home  and 
3cted  houses  should 
1  cleansed.  A  camp 
ty-stricken  patients, 
-space  for  each  pa- 
e  cities  and  in  local- 
3,  a  permanent  fever 


Absolute  cleanliness  in  the  sick  room  must  be  insisted  upon. 
All  soiled  clothes  should  be  thrown  into  a  five  per  cent  solution 
of  carbolic  acid,  or  some  other  disinfectant,  and  then  imme- 
diately washed  in  boiling  water.  Piatt's  chlorides  should  be 
sprinkled  upon  the  bed  and  about  the  room.  After  convalescence 
the  patient's  apartment  should  be  fumigated  by  burning  sulphur, 
nnd  then  thoroughly  aired,  the  woodwork  cleansed  with  carbol- 
ized  water,  and  the  walls  whitewashed.  The  infected  bedding 
should  be  disinfected  by  prolonged  exposure  to  heat  or  to  sul  phur 
fumes,  and  then  shaken  or  beaten  and  exposed  to  the  wind  and 
sunshine  for  several  days. 

Principal  Remedies.— Baptisia  is  oftenest  indicated  in  the 
early  days  of  the  invasion  attack,  and  when  gastric  symptoms 
predominate.  It  is  reported  as  having  lessened  the  severity  of 
the  disease,  and  hastened  the  crisis.  Bryonia  is  the  best  remedy 
during  the  latter  days  of  the  primary  paroxysm,  and  in  the  re- 
lapse. Arsenicum  stands  next  to  bryonia,  and  is  indicated  dur- 
ing the  fever  when  watery  diarrhea  and  vomiting  are  present. 
Eupatorium  perf.  will  be  of  service  when  the  rheumatoid  pains 
are  very  severe,  and  when  there  is  great  tenderness  in  the  epi- 
gastrium and  right  hypochondrium.  Nttx  vom.  is  usually  indi- 
cated during  the  intermission.  Helonin  or  mere.  cor.  may  be 
given  as  an  intercurrent  remedy  for  albuminuria;  and  cantharis 
or  apis  for  diflRcult  urination  with  scanty  discharge.  Urinary 
retention  calls  for  either  opium  or  hyos.  Phosphorus  or  phos- 
phoric acid  will  be  frequently  needed  during  convalescence. 
Berheris  vulg.  will  prove  serviceable  when  there  is  considerable 
enlargement  of  the  spleen;  and  mere,  bi-jod  when  both  the  liver 
and  spleen  are  enlarged. 

Leading  Indications.— Aconite. — In  the  first  paroxysm  when 
there  is  high  fever,  great  restlessness  and  anxiety,  full,  hard, 
quick  pulse,  and  pain  in  the  forehead  and  temples.  Great  thirst 
for  small  quantities  of  cold  water  prevails  during  the  paroxysm 
{ars.,  opp.  bry.).    In  sanguine  and  plethoric  individuals. 

Apis  mel. — Great  desire  to  sleep.  Soreness  of  the  limbs  and 
joints.  Great  soreness  in  the  pit  of  the  stomach  when  touched 
{bry. ).  Soreness  in  the  region  of  the  spleen.  Urine  scanty  and 
high-colored.    Suppression  of  urine  {hyos.,  opium).    Oppres- 


iVMiiii*iiwiiifa«»riar-ai 


i 


32G 


LECTURES  ON   FEVKKS. 


3ion  of  the  chest  with  a  sensation  of  smothering  chiring  the  par- 

oxysm . 

Arnlca.-Great  weariness  compelling  the  patient  to  lie  down 
•  yet  the  bed  feels  too  hard  ( bapi ).    Confused  feehng  m  the  head 
with  pressure  over  the  right  brow.     Great  hea  in  the  head  with 
coldness  of  the  body;  cold  sensation  at  a  small  spot  on  the  fore- 
htd     Heatiller 
if  the  bedclothes  causes  chilliness  {7wx).    Petechia. 

Arseiiiciim.-Great  restlessness  and  anxiety.  »«^th.Uke 
color  of  the  face  (carbo.  vcg.).  Pain  and  distension  in  the  left 
hvpochondrium.  Aversion  to  food.  Tongue  furred  at  the  edges, 
tXred  streakin  the  center,  and  red  tip.  thirst  -cold  wa^r 
wants  little  at  a  time  but  often  (aco.,  mich.,  opp.  hry^).  Burn  ng 
in  the  stomach  with  vomiting  and  diarrhea.  f.«»«l\7«^^^  com- 
pressible pulse.  Great  weakness  and  prostration  after  the  par- 
oxysm  {verat.  nib.).    (Edema  of  the  extremities. 

BaDtisia.-Great  nervous  restlessness,  especially  at  night 
DuU  u^^fying  headache  (gels.).  Head  feels  as  if  scattered 
Tbout;  tres  I  get  the  pieces  together.  Dark,  red  face  with  be- 
oSexpression.  Tongue  coated,  brown  and  ^ry,  paxticu^.rl 
in  the  center.  White  furred  tongue  with  red  «dg;«;  Jiref ' 
bruised  sick  feeling  all  over  the  body.  Feeling  as  if  the  lower 
M)s  were  separated  from  the  body  iopinm).  Patient  changes 
pTsul"  frequ^ently  because  the  bed  becomes  too  hard  (armca). 
Offensive  secretions. 

Bryonia.- Desire  to  lie  down  during  the  fever;  setting  up 
causesnausea  and  vomiting;  vomiting  lirstofbiM^^^^ 
Yxolent  throbbing  headache,  as  if  the  head  would  burst  Ver^go 
with  sensation  as  of  the  head  turning  in  a  circle  {bell).  White 
Ir  yellow  coating  on  the  tongue.  E'.ces.ive  thirst,  drinks  large 
quan  ?ils  at  a  tfme.  and  at  long  intervals.  Stitches  m  the  liver 
and  spleen  (mere).  Sweat  on  single  parts  only,  or  on  side  on 
whch  the  patient  lies.  Neuralgic  and  rheumatic  pains,  worse  on 
^oSon.  Fullness  and  oppression  in  the  p  t  of  the  stomach  and 
bowels.    Epigastric  region  painful  to  touch  and  pressure. 

Pflmnhor —Sudden  and  great  sinking  of  strength  {ars.). 
CoW  s'e!  'all  ^w  the  body  (.W.  „».).  Sudden  sink.ng 
sHk     Small,  weak,  scarcely  perceptible  puUe  (carbo.  veg.). 


LEADING   INDICATIONH. 


327 


ring  during  the  pnr- 

patient  to  lie  down, 
feeling  in  tlie  head 
ant  in  the  head  with 
jail  8i)ot  on  the  fore- 
|the  Blightest  motion 
'etechiae. 

nxiety.  Death-like 
listension  in  the  left 
furred  at  the  edges, 
["hirst  for  cold  water, 
opp.  6r^.).  Burning 
Small^  weak,  corn- 
ration  after  the  par- 
aities. 

especially  at  night. 

feels  as  if  scattered 
irk,  red  face  with  be- 
laud dry,  particularly 
h  red  edges.  Tired, 
eeling  as  if  the  lower 
•n).  Patient  changes 
es  too  hard  (arnica). 

the  fever;  setting  up 
of  bile,  then  of  fluids, 
would  burst.  Vertigo 
^iTc\e  (bell).  White 
e  thirst,  drinks  large 
Stitches  in  the  liver 
I  only,  or  on  side  on 
matic  pains,  worse  on 
t  of  the  stomach  and 
I  and  pressure. 

of  strength   {ara.). 

».).    Sudden  sinking 

pulse  {carbo.  veg.). 


Great  thirst;  coldness  of  the  tongue  {carbo.  veg.,  verai.  alb.). 
Extreme  sensibility  to  cold  air  {mix). 

Chaiiioniilla. — In  chilcben  and  in  nervous  adults.  Gastric 
symptoms  {bajtt.).  Excessive  sensitiveness  to  pain  {coffea). 
Yellow  coated  tongue.  Tongue  white  at  the  sides  and  red  in  the 
middle  (opp.  iart.  cmet. ).  Frequent  emissions  of  large  quantities 
of  pale  urine  {helonin). 

Cimicifuga. — Neuralgia  in  the  forehead  and  eyeballs.  Sink- 
ing sensation  at  the  stomach  with  nausea  and  vomiting.  Ner- 
vous weakness  and  prostration.  Excessive  muscular  soreness. 
Obstinate  sleeplessness.     Threatened  abortion. 

Cinchona. — Sense  of  internal  illness  as  of  impending  disease. 
Pressure  in  the  head  from  within  outwards  as  if  it  would  burst, 
lelieved  by  hard  pressure.  Great  lassitude  and  exhausting 
eweats  during  the  intermission.  Saffron  yellow  color  of  the  skin; 
the  patient  looks  jaundiced.  Enlargement  of  the  liver  and 
spleen.     Anaemic  and  cachectic  appearance. 

Enpatorium  perf. — Headache  with  sore  feeling  internally. 
Nausea  with  retching  and  vomiting  of  bile.  Bone  pains  in  every 
stage.  Pain  in  the  back  and  limbs  as  if  bruised  {am. ).  Thickly 
coated  tongue  with  thirst  and  vomiting  after  drinking.  Sallow- 
neas  of  the  skin;  morning  diarrhea  {podo.).  Perspiration  in- 
creases the  headache,  but  relieves  all  the  other  pains  {nat.  miir.). 
Soreness  of  the  region  of  the  liver  on  pressure  (mere).  Great 
tenderness  of  the  epigastrium.  Loose  cough  during  the  inter- 
mission. 

Oelsemium. — Dullness  of  the  mental  faculties  {bapt ).  Great 
languor  and  drowsiness.  Bruised  pains  in  the  muscles,  general 
rheumatic  symptoms  {dm.).  The  tongue  is  coated  whitish  or 
yellowish  and  there  is  a  sticky  feeling  in  the  mouth.  Intense 
burning  fever  accompanied  by  a  sensation  of  falling.  Sweat  is 
apt  to  be  profuse  and  relieves  the  pain  {nat  mur.,  opp. /errum). 
In  children  and  nervous  young  people. 

Leptandra. — Dull  aching  pain  in  the  liver  {mere.).  Burning 
distress  in  the  epigastric  and  hypochondriac  regions.  Constant 
nausea  with  vomiting  c  r  bile.  Jaundice  with  clay-colored  stools. 
Thin,  black,  fetid,  watery  evacuations  with  severe  pains  after 
stool.     Chronic  diarrhea  and  dysentery.     Brownish  urine. 


.1--  <A»  i^m.iA..  •itm'-f'tttibKMi 


mtnt'¥mmi^rt.'t4n»w»m 


■numii— WHLi^ 


milBtot^a  WW  twtfo 


328 


LECTURES  ON  FEVERS. 


Mercurius.— Great  anxiety  ami  reatlessness.  Heaviness  in' 
the  head  with  great  inclination  to  sleep.  Swollen,  soft,  flabby 
tongue,  taking  the  imprints  of  the  teeth.  Dirty-yellow  coating 
on  the  tongue.  Region  of  the  liver  painful  and  sensitive  to  con- 
tact {hry.,  cupat  perf.).  Icteroid  hue  of  the  skin.  Tearing 
pains  in  the  joints,  worse  at  night  and  in  the  warmth  of  the  bed. 
Bilious,  slimy  or  watery  diarrhea.    Sudamina. 

Nux  vom. — Gastric  or  bilious  symptoms  predominate.  Hun- 
ger with  great  aversion  to  food.  Flatulent  distention  of  the 
abtiomen  after  eating  {cinch.,  lycop.).  Alternate  constipation 
and  diarrhea  (  hry. ).  Throbbing  in  the  region  of  the  liver  ( hry. ). 
Profuse  sweat  after  the  severest  paroxysms.  Chilliness  on  mov- 
ing the  bedclothes.    Has  been  recommended  as  a  preventive. 

Phosphorus.— Pale,  sallow,  or  changeable  color  of  the  face. 
Inability  to  concentrate  thought  {am.,  rhtis).  Thirst  with  de- 
sire for  very  cold  drinks  {rhns).  Region  of  the  stomach  painful 
to  the  touch.  Feeling  of  coldness  in  the  abdomen  {ars. ).  Hard, 
dry  cough  with  oppression  in  the  chest.  Loud  mucous  rales  in 
the  lower  lobes  {ipecac,  tart.  emet. ) .  Hepatization  of  the  lungs. 
Rose  spots  and  ecchymoses.     Profuse  epistaxis. 

Phosphoric  acid.— Pale,  sickly  complexion.  Hemorrhage 
from  the  nose  of  dark  blood  {ham.).  Grayish  coating  on  the 
tongue.  Headache,  worse  from  the  least  shaking  or  noise  (  hell. ). 
Feeling  of  heaviness  in  the  region  of  the  liver  {podo.).  Fre- 
quent, small,  feeble  pulse.  Profuse  night  {mere,  tarax.)  and 
morning  {cinch.)  sweats.  Pressure  in  the  stomach  after  eating. 
Thin,  whitish-gray  evacuations.  In  young  persons  who  have 
grown  very  rapidly. 

Rhus  tox.— Fullness  and  heaviness  in  the  forehead,  worse 
from  opening  or  moving  the  eyes  {puis.).  Dark,  livid  redness 
of  the  cheeks.  Dry,  red,  cracked  tongue  {hapl).  Redness  of 
the  tip  of  the  tongue  in  the  shape  of  a  triangle.  Great  thirst 
for  cold  drinks  {phos.),  especially  cold  milk.  Dry,  tickling 
cough  worse  in  the  evening  and  before  midnight.  Profuse  sour 
morning  sweats.    Erysipelas  with  great  burning. 

Sambttcus.— Intense  heat  with  great  dread  of  uncovering. 
Excessively  abundant  sweat.  The  perspiration  continues  through 
the  intermission.  (Edematous  swelling  of  the  feet,  instep  and 
lower  part  of  the  legs. 


HYQIENIO  AND  DIETETIC  TREATMENT. 


329 


Bs.  Heaviness  in' 
oUen,  soft,  flabby 
rty-yellow  cdating 
cl  sensitive  to  con- 
lie  skin.  Tearing 
rarmth  of  the  bed. 

edominate.  Hiin- 
distention  of  the 
mate  constipation 
of  the  liver  (6r?/.). 
Chilliness  on  mov- 
as  a  preventive. 

color  of  the  face. 
I.  Thirst  with  de- 
le  stomach  painful 
iien( «rs.).  Hard, 
id  mucous  rales  in 
lation  of  the  longs, 
is. 

on.  Hemorrhage 
ish  coating  on  the 
ingor  noise  (6eH.). 
ver  (podo.).  Fre- 
nerc,  tarax.)  and 
)mach  after  eating, 
persons  who  have 

ae  forehead,  worse 
Dark,  livid  redness 
apl. ).  Redness  of 
agle.  Great  thirst 
ilk.  Dry,  tickling 
ght.  Profuse  sour 
ling. 

sad  of  uncovering, 
a  continues  through 
he  feet,  instep  and 


Terebinthiiia.— Headache  with  intense  pressure  and  fullness 
of  the  head.  Tongue  red,  smooth  and  glossy.  Vomiting  of  mu- 
cus, bloml  or  bile.  Small,  weak,  thready  pulse.  Cold,  clammy 
sweat  all  over  the  body  {vend.  alb.).  Burning,  drawing  pains 
in  the  kidneys  with  bloody  urine.    Strangury.    Great  prostration. 

Veratruni  alb.— Sudden  sinking  of  strength.  Hippocratio 
countenance.  Cold  perspiration,  especially  on  the  forehead. 
Tongue  cold  {carbo.  ve(j.)or  coated  white  with  red  tip  and  edges. 
Violent  thirst  for  cold  water  {nrs.,  lilios. ) .  Spasmodic  constric- 
tion of  the  throat.  Suppression  of  urine  {apis).  Nausea  and 
vomiting  with  frequent  serous,  watery  or  bloody  stools  {momor- 
dica).    PetechitB  on  the  extremities. 

HYGIENIC    AND  DIETETIC    TREATMENT. 

Relapsing  fever  patients  should  be  kept  quiet  in  bed  during 
the  primary  paroxysm,  and  free  ventilation  secured.  The  bed 
and  room  should  be  sprinkled  with  Piatt's  chlorides,  oi  some 
other  disinfectant.  The  bed  and  body  linen  should  be  changed 
daily  and  thrown  into  a  vessel  containing  a  solution  of  carbolic 
acid  before  being  removed  from  the  room,  and  afterwards  washed 
in  boiling  water.  All  unnecessary  visiting  should  be  prohibited, 
and,  as  a  rule,  the  sick  should  not  bo  allowed  to  leave  their  rooms 
until  the  period  of  relapse  shall  have  passed. 

A  carefully  regulated  and  nourishimj  diet  is  of  the  utmost  im- 
portance, because  deficient  alimentation  has  in  the  majority  of 
cases  been  a  predisposing  cause.  From  one  to  two  quarts  of 
milk  should  be  administered  daily  during  the  paroxysm.  Meat 
broths  and  light  farinaceous  food,  ice  cold  koumyss,  weak  iced  tea 
with  lemon-juice,  and  other  cooling  drinks  may  be  allowed. 
Buttermilk  is  often  exceedingly  grateful  to  patients  and  is  highly 
beneficial. 

When  the  temperature  begins  to  decline  and  sweats  appear, 
the  body  should  be  kept  dry,  and  warm  nourishing  drinks  and 
warm  applications  resorted  to. 

During  the  intermission  as  much  substantial  food  as  can  be 
digested  should  be  allowed. 

Any  tendency  to  heart-failure  at  the  time  of  the  crisis,  or  early 
in  convalescence,  should  be  obviated  by  the  early  use  of  wine, 
champagne  or  spirits.    The  pulse  and  the  character  of  the  first 


LECTURES  ON  FEVEB8. 


sound  of  the  heart  are  the  best  guides  as  to  the  amount  of  stim- 
ulation necessary. 

Excessive  tenderness  of  the  spleen  and  liver  moy  be  relieved 
by  the  use  of  fomentations  and  poultices.  The  tumoned  spleen 
may  be  decidedly  reduced  in  volume  by  means  of  the  induced 
electric  current.  With  partial  suppression  of  urine  at  the  crisis, 
flaxseed  poultices  to  the  loins  are  beneficial. 

As  the  patient  enters  upon  convalescence  after  this  blood-in- 
fection, pure  air  and  good  diet,  mental  ond  bodily  rest,  are 
especially  desirable. 


1 


the  amount  of  stim- 

iver  may  be  relieved 
The  tumoned  spleen 
Jans  of  the  induced 
Df  urine  at  the  crisiB, 

3  after  this  blood-in- 
ind  bodily  rest,  ore 


LECTUKE  XXI. 

Small-Vox. 

,e,«„  that  are  specially  ch»r»cfemedoy  1^^_^  .^^  ^^^^^^ 

have  been  ^"-'^^'^^Zl^rM  varicUa  or  Mokeu- 

„t  incubation.    They  run  actear^y  <'«»  „„„  „,,;„!, 

tended  by  active  febrile  «rPfr;Cgea  and  then  disappears, 
pa^ea  through  a  res^larBenesjf  "hang  ^^  ^^  ^^^ 

They  are  all  contagious,  and,  aa  a  rule, 

'trist  remarkable  of  all  the  eruptive  fevers,  and  the  first 
of  which  I  shall  speak,  is  small-pox.  contagious 

Beftnition.-.It  may  ^^^f  ^^.^  ^  ^^^^^  a 

fever,  of  from  two  to  ««« J^%\Vcutaneous  and  mucous  sur- 
pustular  inflammation  of  ^j'^  ^^^^^^^jaerable  constitutional 
Les,  accompanied  by  symptoms^fon^^^^^^^     ,,heredinby 

disturbance.    It  consists  o^-  J^^^^^^        ^^^^^^,  headache 

a  chill,  and  marked  by  f^^/^^^'/^hroat,  active  fever,  rapid 
pain  in  the  small  of   he  ^a^^,  ^^^^^^^^^  ^^^^    ^  j,,iage 

Use,  and  occasionally  an  ^"^^"f  J^^^^^^^^^  the  disease  by  a  red- 
of  eruptions  introduced  on  *he  thi^^^^^^^^^^        ,„d  marked  by  sud- 

dish,  millet-seed  f  P^I^^^^^^^m^^^^^^  -uption  as  it  develops 
den  subsidence  of  febrile  symptoms  p  ^^^^^ 


r 


S32 


LECTUUEH  ON   FEVElia 


iHJComing  ,lnrk-rnd  and  pnpulnr  on  the  fourth  dny,  HliRhtly 
voH.oular  ..n  ti.o  sixth  dny,  c..,nph.t..ly  voHienlnr.  pea-Hi/.d  ami 
fmpu.ntly  un.l..h(.at...l  .„,  tho  noventh  ,.r  oi«hth  day.  JJ.  A  Htane 
of  ^u,>f>,m,lion  .m  the  .u«htii  or  ninth  .lay  .,f  tho  diHoano.  when 
th.,  puHtuh.8  are  fully  formed,  secondary  fever  ccnnos  on  tho 
temperature  rises  as  high  or  even  higher  than  (hiring  the  initial 
Btage.  migmentation  of  all  tin,  symptoniB  oecurs,  the  faee  swells 
general   itching  becomes   int<.leral,le.  an.l   tho  patient  emits  a 

twflfV;  '■  r  ;.  r'"-"'  "/''-'■'•'•"''>'«  »•">"*  the  eleventh  or 
twelfth  day  of  the  .lisease,  when  tho  pustules  hurst  and  crusts 
oi  scahs  form,  the  temperature  falls,  and  the  appetite  returus- 
the  crusts  eventually  falling,  leaving  pigmented  cicatrices  imd 
occasionally  pits.  After  death,  constant  lesions  of  the  cutaueoua 
surface,  lungs,  brain,  liver,  spleen  and  kidneys  are  found. 

Synonym.-Its  common  synonym  and  first  name  is  variola. 
The  term  vurioh,  the  diminutive  of  varus,  a  pimple,  is  of 
monkish  ongin,  but  was  first  applied  to  this  disease  by  Constant 
tinus  Afncanus^  The  term  pock  is  of  Saxon  origin,  and  signifies 
a  bag  or  sac.  The  epithet  .mall,  was  added  to  it  soon  after  the 
intrcKluction  of  the  great  pox  (syphilis)  into  Scotland  from 
America  m  1498. 

Hlstory.-Although  small-pox  had  certaiply  been  known  for 
several  centuries  before  it  was  described,  the  earliest  clear  ac- 
count of  It  was  given  by  Gregory,  of  Tours,  in  the  year  581 
Ithazes  an  Arabian  physician  who  practiced  in  Bagdad,  gave  the- 
first  full  and  scientific  description  of  the  disease  in  910. 

The  success  of  the  Saracen  arms  in  Spain  and  Sicily  in  the 
eighth  century  assisted  the  spread  of  small-pox  throughout  Eu- 
rope Traveling  westward  it  reached  England  about  the  close 
of  the  ninth  century. 

It  raged  throughout  Europe  about  the  time  of  the  crusades, 
and  visited  England  again  in  1241.  Pest-houses  were  first  gen- 
erally erected  at  this  time  for  the  purpose  of  checking  the  dis- 
ease and  of  affording  assistance  to  sufferers. 

At  the  close  of  the  fifteenth  century  it  started  in  the  Nether- 
lands and  extended  to  Germany  and  Sweden. 

It  was  introduced  into  Mexico-its  first  appearance  on  this 
contment-in  1520,  by  a  negro  slave.  This  epidemic,  as  is  the 
rule,  when  diseases  first  appear  in  any  country,  was  unusually 


riiMMUUi'iiu-ti^iin 


""ril'iTliiliHW&illlllMllllili  I 


HISTORY. 


m:\ 


fourth    ,I„y,    slightly 

kulnr,  pen-Hiztxl  and 

|K''th(lny.    a  A«/m/o 

«»'  tho  (liHojiHo,  when 

'«ver  c(»nioH  on,  tho 

inn  (hiring  th.>  initinl 

<'iirH,  tlio  fnco  HwoJIs, 

tho  patient  einitH  a 

I'oiit  the  eleventh  or 

il^'H  hurHt  nnd  crusts 

<^»ppetite  returuH— 

lented  cicntric(*H  juad 

onsof  thecutouoous 
'y«  are  found. 

'•8t  name  is  variola. 
'"*,  a  pimple,  is  of 
disease  by  Constnn- 
origin,  and  signifies 
I  to  it  Boon  after  the  ' 
nto  Scotland  from 

iply  been  known  for 
ie  earliest  clear  ac- 
,  in  the  year  681. 
in  Bagdad,  gave  tli» 
ase  in  910. 

1  and  Sicily  in  the 
ox  throughout  Eu- 
id  about  the  close 

•e  of  the  crusades, 
ses  were  first  gen- 
checking  thedis- 

ed  in  the  Nether- 

>pearance  on  this 
)idemic,  as  is  the 
y.  was  unusually 


Hpvorc,  and  proved  alarmingly  fatal.  According  to  Spniiish  liis- 
toriaiiH,  in  Mexico  alone,  three  and  one-half  millitms  of  people 
f«>ll  victinr.;*  to  tho  scourge.  In  Hayti  it  carried  off  all  the  inhnb- 
itantH,  and  in  Brazil  whole  tril>eH  wisro  completely  destroyed. 

lu  the  seventeenth  and  eighteenth  centuries  it  prevailed  in 
England  and  in  Europe,  and  was  the  greatest  scourge  of  the  age. 
As  a  proverb  of  the  times  exprossed  it,  "from  small-pox  and 
love,  but  few  remain  free."  Snmll-pox  was  first  definitely  sep- 
arated  from  measles  by  Sydenham  in  lOIW. 

In  1049,  8mall-i)ox  first  occurred  in  Boston,  and  afterward  re- 
appeared every  tlecade  during  the  century. 

In  1721,  one-half  of  the  population  of  Boston  was  attacked 
with  the  disease,  and  one-thirteenth  of  those  attacked,  died. 

In  1767,  a  terribly  fatal  epidemic  raged  in  Greenland,  Siberia 
and  Kamtchatka. 

During  the  sixteen  years  following  1783,  it  is  stated  that  one- 
tenth  of  the  total  mortality  at  Berlin,  was  due  to  small-pox. 

Am  epidemic  most  remarkable  for  its  extensive  difTusion,  began 
in  Sweden,  in  1824 — reached  England  in  1825,  spread  to  France 
in  1826-27,  and  ceased  in  Italy  in  1828-29. 

Several  epidemics  occurred  at  Copenhagen  from  1825  to  1835. 

In  1838,  one  hundred  and  fifty  thousand  Mandan  Indians,  a 
branch  of  the  Sioux  located  on  the  Missouri  river,  died  of  the 
disease,  leaving  only  twenty-seven  of  the  tribe,  now  located  nt 
Ft.  Clarke.  Catlin  asserts,  that  of  twelve  millions  of  American 
Indians,  six  millions  have  been  destroyed  by  small-pox. 

In  the  island  of  Bombay  during  the  five  years  following  1848, 
the  small-pox  deaths  among  the  unprotected  were  about  six  per 
cent  of  the  mortality  from  all  causes,  and  among  the  protected 
(vaccinated)  one  per  cent. 

In  1870-71,  a  terrible  epidemic  ravaged  Europe,  and  in  1871- 
72  the  disease  prevailed  to  a  considerable  extent  in  Philadelphia. 

In  the  winter  of  1881-82  it  prevailed  in  New  York,  Chicago 
and  Quebec,  and  in  several  other  large  cities  of  this  country 
and  Canada. 

Few  countries  have  remained  exempt  from  small-pox.  At  va- 
rious periods  new  and  destructive  epidemics  have  broken  out  in 
all  parts  of  the  world.  The  spread  of  the  disease  depends 
greatly  upon  the  manner  in  which  the  eminently  protective  rem. 
edy,  vaccination,  is  employed.    For,  to-day,  amongst  the  unpro- 


MfMaililiaiJaliHittab. 


"  *-  f  „f-^'"«J--l 


334 


LECTUIiES   ON   FEVERS. 


tected  (wm-raccinaied),  small-pox  is  as  destructive  and  virulent 
as  in  tlie  i)nst. 

Etiology. — The  causes  of  small-pox  are,  predisposing  and  ex- 
citing. :' 

1.  Tlic  Predisposing  Causes. — Climnic  has  no  direct  influence 
in  producing  this  disease. 

The  season  of  ihe  year  exerts  very  little  influence.  Epidem- 
ics arise  and  pursue  their  course  irrespective  of  seasons.  The 
disease  is  usually  more  fatal  in  summer  than  in  winter. 

Age  exerts  some  influence  as  a  predisposing  cause.  The  ex- 
tremes of  life  are  those  on  which  small-pox  falls  the  heaviest, 
[mmunity  is  reached  at  no  period,  and  even  uterine  life  does  not 
exclude  the  danger  of  infection.  The  susceptibility  is  greatest 
iv.    nildren  from  the  seventh  to  the  fourteenth  year. 

Sex,  in  itself,  has  no  influence. 

Occupation,  except  as  it  involves  actual  exposure,  does  not 
predispose  to  small-pox. 

Race  and  nationality  exert  some  influence.  The  negro  and 
Indian  races  ajjpear  to  be  particularly  susceptible.  As  a  rule, 
they  sufi'er  more  violently  than  the  white  races,  even  under  the 
same  conditions. 

Pregnant  women  are  apt  to  abort  or  miscarry  during  the  course 
of  small-pox.  The  foetus  usually  perishes,  occasionally  it  sur- 
vives. 

Lying-in  icomen  are  predisposed  to  the  confluent  form  of  the 
disease,  which  frequently  terminates  fatally. 

A  previous  attack,  as  a  rule,  extinguishes  the  susceptibility  to 
the  disease.  Cases  of  secondary  or  recurrent  small-pox,  how- 
ever, have  been  described  in  all  ages  from  Bhazes  down  to  the 
present  time. 

Non-vaccination  exerts  a  powerful  influence.  A  system  un- 
protected by  successful  vaccination  is  strongly  predisposed  to 
small-pox. 

2.  The  Exciting  Cause. — Small-pox  is  pre-eminently  conta- 
gious, and  is  due  to  a  specific  poison,  communicable  from  the 
sick  to  the  healthy  by  actual  contact  (upon  mucous  or  abraded 
surfaces)  through  the  atmosphere,  by  fomites,  and  by  drinking 
water.  The  exact  nature  of  this  poison  remains  as  yet  unknown, 
although  many  writers  assert  its  parasitic  origin.  It  is  developed 
and  reproduced  in  the  body  of  a  small-pox  patient,  first  takes 


Iirwr  I  -. 


ETIOLOGY. 


335 


ERS. 

;s  destructive  nnd  virulent 

are,  predisposing  nud  ex- 

rifc  has  no  direct  influence 

little  influence.  Epidpni- 
ispective  of  seasons.  The 
iT  than  in  winter, 
(disposing  cause.  The  ex- 
lall-pox  falls  the  heaviest. 
.  even  uterine  life  does  not 
i  susceptibility  is  greatest 
urteenth  year. 

actual  exposure,  does  not 

nfluence.  The  negro  and 
•ly  susceptible.  As  a  rule, 
'hite  races,  even  under  the 

miscarry  during  the  course 
rishes,  occasionally  it  sur- 

>  the  confluent  form  of  the 

fatally. 

uishes  the  susceptibility  to 

recurrent  small -pox,  how- 

3  from  Ehazes  down  to  the 

influence.     A  system  un- 
is  strongly  predisposed  to 

)x  is  pre-eminently  conta- 
i,  communicable  from  the 
,  (upon  mucous  or  abraded 
y  fomites,  and  by  drinking 
)n  remains  as  yet  unknown, 
jitic  origin.  It  is  developed 
all-pox  patient,  first  takes 


effect  upon  the  patient  himself  and  is  present  in  the  blood  and 
in  the  contents  of  the  pustule.  .    , ,    ,         .,       .,    x,,  .],^ 

The  disease  is  constantly  communicable  from  the  «  ck  to  ttie 
well  by  actual  contact  of  the  virus  taken  from  a  small-pox  pus- 
ule  with  the  mucous  membrane  or  with  an  abrasion  of  the  cu- 
taiemxrsurface.     It  is  also  communicable  from  one  individual 
toTnotler  by  means  of  the  expired  air,  and  the  cutaneous  exha- 
tt  ons     The  distance  to  which  it  may  be  thus  conveyed'  in  «ie 
irn  air  is  about  two  and  one-half  feet.     In  a  small  and  impei  - 
rtly^ied  apartment  the  atmosphere  may  become  so  impreg- 
naVed  wUh  the  infecting  principle  that  a  predisposed  person  wdl 
beclrinf ected  upon  a  single  entrance  into  the  apartment.    In 
C  and  spacious  rooms  and  in  the  open  air,  the  danger  of  con- 

^X  bre^l^oLtXox  patient  frequently  con.eys,  and  Ms 
bodven^is,  especially  after  the  inauguration  of  th«  ^-PP'^f  ^^ 
l:Z:lrM^^^  -kly  o.ion  It  has  been  thojhUhat  a 
patient  in  whom  this  odor  is  strongly  marked,  is  most  likely  ta 

communicate  the  disease.  j.  ^       .  ,,^^_  +1,0  natient 

Besides  impregnating  his  immediate  atmosphere,  the  patient 

imparts  tielntagion  to  all  articles  with  which  he  comes  in  con- 

IT  In  th's  way  not  only  the  clothing  and  bedding  of  the 

.      .  „.d  dthes  of  his  attendants,  but  also  the  apartment 
patient,  and  the  clothes  01  ms  substances  are 

in  which  he  has  lain  may  act  as  Jomites.     vvooiy  »"" 
espec^y  apt  to  absorb  and  retain  the  contagum.  which  under 
ZrS^ciLnistancesmayretainitsvirulenceayjt-^^^ 
Exposure  to  the  atmospheric  air  sooner  or  later  destroys  it 

S  period  at  which  a  small-pox  patient  is  most  likely  ta 
spread  ""the  infection  is  the  period  of  suppuration.  Infection 
m'^aT  however,  take  place  during  any  stage,  even  during  the 

^t:luUrttt  contracted  by  -eptib ^-^  ^^^^^^^^ 
contact  with  bodies  of  persons  who  have  died  of  it.     Th^reis  na 
evidence  that  it  can  be  conveyed  by  the  discharges  from  the 

^T^e  period  of  incubation  varies  from  ten  to  thirteen  days. 

Varietie8.-The  common  and  well-recognized  varieties  of 
smauTox  are:  1.  Distinct  or  moderaie  small-pox,  in  which  the 
Ztules  remain  separate  from  each  other  during  the  whc^e 
^uleof  the  disease;  rarely  fatal.     2.  Canfiuent  small-pox  lu 


M^Mh  iiaiiiiii'iiiiii^wi"^'^'^'""'- 


836 


LECTURES  ON  FEVERS. 


which  the  pustules  run  together  on  the  face  or  all  over  the  body- 
dangerous  to  life.  3.  Hwmorrhagic  small-pox  in  which  there  is 
a  bruised  appearance  from  extensive  capillary  hemorrhages- 
usually  fatal  on  the  third  day.  ' 

Clinical  History.-The  clinical  history  embraces  a  descrip- 
tion of  the  period  of  incubation,  the  initial  stage,  the  stage  of 
eruptions,  the  stage  of  suppuration  and  the  stage  of  desiccation 

The  period  of  incubation,  or  the  time  elapsing  between  the 
reception  of  the  poison  and  the  onset  of  the  disease,  varies  from 
ten  to  thirteen  days.  If  the  poison  is  introduced  into  the  sys- 
tem  through  inoculation,  the  duration  of  this  period  is  shortened 
to  two  days. 

Stage  of  Initial  Fever.-Vpon  the  termination  of  the  period 
•of  incubation— usually  twelve  days  after  the  exposure— the  at- 
tack  18  ushered  in  by  a  feeling  of  chilliness  which  frequently 
increases  to  a  distinct  chill,  with  severe  and  characteristic  pams 
m  the  loins,  accompanied  with  frontal  headache,  and  soon  fol- 
lowed  by  high  febrile  excitement.     The  pulse  is  commonly  full 
and  frequent,  rising  to  100  or  120,  or  even  to  140  per  minute:  in 
children  it  may  reach  160.    The  temperature  rises  rapidly  and 
may  reach  104°  Fahr.  on  the  first  day,  105°  Fahr.  on  the  second 
day,  and  106    Fahr.  or  107°  Fahr.  or  even  higher  on  the  third 
day     The  patient  is  languid  and  weak  in  proportion  to  the  se- 
verity  of  the  fever.     Not  infrequently  within  twenty-four  hours 
after  the  ushering-in  chill,  the  infected  individual,  strong  and 
vigorous  in  health,  will  be  unable  to  get  out  of  bed. 

The  skin  feels  hot  and  dry,  or  else  is  covered  with  a  moderate 
perspiration.  The  face  is  flushed,  the  conjunctiva  are  injected, 
and  there  IS  throbbing  of  the  carotids.  The  tongue  is  red  at  the 
tip  and  edges,  and  there  is  nausea  and  vomiting  with  epigastric 
pam  and  obstinate  constipation.  There  is  soreness  of  the  throat 
with  pain  m  the  pharynx  and  more  or  less  difficulty  in  swallow- 
mg.  The  respirations  are  short,  frequent  and  labored.  Towards 
evening,  on  the  second  or  third  day,  there  may  be  delirium;  in 
children  delirium  and  convulsions  may  occur  at  the  onset  of  the 
attack. 

Swelling  and  diflFuse  redness  of  the  tonsils  and  soft  palate  are 
usually  apparent  at  the  close  of  the  second  day,  and  occasionally 
minute  reddish  papules  may  be  recognized  upon  these  parts.  At 
times,  especially  in  children,  and  in  women  during  menstruation 


1« 


J 


r  all  over  the  body; 
)x  in  which  tliere  is 
llary  hemorrhages; 

mbraces  a  descrip- 
stage,  the  stage  of 
age  of  desiccation, 
psing  between  the 
lisease,  varies  from 
uced  into  the  sys- 
Jeriod  is  shortened 

ition  of  the  period 
exposure — the  at- 
which  frequently 
haracteristic  pains 
che,  and  soon  fol- 
J  is  commonly  full 
L40  per  minute;  in 
rises  rapidly,  and 
ahr.  on  the  second 
fher  on  the  third 
(portion  to  the  se- 
twenty-four  hours 
vidual,  strong  and 
!bed. 

i  with  a  moderate 
tivaB  are  injected, 
ngue  is  red  at  the 
gwith  epigastric 
ness  of  the  throat 
iculty  in  swallow- 
ibored.  Towards 
Y  be  delirium;  in 
1  the  onset  of  the 

id  soft  palate  are 
and  occasionally 
I  these  parts.  At 
ng  menstruation 


CLINICAL  fixoiORY. 

and  confinement,  a  bright  or  dull  crimson,  erythematous  rash 
appears,  of  tenest  about  the  groins,  liypogastrium  and  inner  sur- 
face of  the  thighs.  Less  frequently  it  is  observed  about  the 
axilliw,  the  exterior  surfaces  of  the  joints,  and  the  lumbar  and 
clavicular  regions.  It  apjjears  mostly  about  the  second  day,  and 
lasts  about  twenty-four  hours,  fading  almost  completely  as  the 
characteristic  variolous  eruption  appears. 

Stage  of  Eruptions. — On  the  third  day  of  the  disease — some- 
times earlier  in  severe  and  confluent  cases — an  eruption  appears 
upon  the  face,  especially  along  the  edges  of  the  hair,  in  the  form 
of  small,  red,  elevated  papules,  resembling  measles.  These  little 
points  which  rapidly  increase  in  numbers,  soon  cover  the  fore- 
head, nose  and  upper  lip,  and  extending  within  twelve  hours  to 
the  neck,  arms,  trunk  and  lower  extremities,  cover  the  entire  body. 
Their  site  is  usually  around  a  hair-follicle  or  the  orifice  of  seba- 
ceous or  sweat  glands.  They  are  frequently  arranged  in  three's 
■and  five's  in  a  crescentic  shape,  two  crescents  often  coming  to- 
gether to  form  a  circle.  They  are  at  first  millet-seed  or  pin-head 
sized,  and  are  of  a  pale  red  color,  resembling  flea-bites.  Soon 
they  become  conical  pt-I  hard,  and  feel  almost  like  shot  under- 
neath the  skin.  They  g'.  'n'jlly  increase  in  size,  and  on  the  third 
day  of  the  eruption  i'  i.  vesicular  point  is  formed  at  their 
apex.  This  conversion  i  '  u-^jules  into  vesicles  occurs  first  on  th-^ 
face,  and  then  on  the  neck,  trunk  and  extremities.  Within  the 
next  two  days  the  vesicles  enlarge  to  the  size  of  a  small  pea,  and 
become  indented  or  umbilicated.  They  are  nearly  hemispher- 
ical, and  are  surrounded  by  small,  inflamed  areolae.  Their  con- 
tents, which  are  at  first  transparent,  become  whitish  and  milky. 
The  umbilication  of  the  vesicle  is  characteristic,  although  all 
vesicles  are  not  umbilicated.  On  or  about  the  second  dry  of  the 
eruption  the  red  elevations  which  appear  on  the  buccal  mucous 
membrane  simultaneously  with  or  previous  to  the  emption  on 
tlie  skin,  assume  the  appearance  of  small,  whitish,  circular  um- 
bilicated points. 

As  the  eruption  appears,  the  febrile  symptoms  subside,  the 
pains  in  the  head  and  back  vanish,  the  temperature  falls  two  or 
three  degrees,  and  the  pulse  is  diminished  in  frequency. 

Stage  of  Suppuration. — On  or  about  the  sixth  day  of  the  erup- 
tion, and  the  ninth  day  of  the  disease,  the  A'esicles  gradually 
become  turbid  from  the  admixture  of  pus  corpuscles.    Within 


1  i 


338 


LECTUUE8  ON  FEVEHS. 


tlie  next  two  days  the  pustules  become  fully  formed,  maturiuj^ 
first  oil  the  face  and  upper  part  of  the  body,  and  lastly  on  tin* 
extremities.  With  the  process  of  suppuration,  a  new  fever  to 
which  the  term  secomlary  or  suppurative  fever  is  applied,  makes 
its  appearance  either  alone  or  preceded  by  a  distinct  chill,  niul 
lasts  between  four  and  six  days.  The  temperature  rapidly  rises 
to  103°  Fahr.  or  104°  Fahr.;  and  sometimes  to  108°  Fahr.  or 
109°  Fahr.  at  the  height  of  suppuration.  The  pulse  becomes 
hard  and  full,  and  fluctuates  between  100  and  140  beats  per  min- 
ute. The  headache  returns,  and  passive  delirium  not  infrequently 
occurs.  The  face  and  eyelids  swell,  so  that  the  features  are  nu 
longer  to  be  recognized.  The  skin  becomes  tense,  hot  and  dry, 
and  emits  a  characteristic  fcetid,  sickly  odor.  In  the  vicinity  of 
the  pustules  it  becomes  red,  tumefied  and  painful;  each  pustule 
being  surrounded  by  a  hard,  broad,  red  areola.  The  itching 
now  becomes  intense.  The  swelling  and  soreness  of  the  throat 
increases,  and  swallowing  becomes  painful  and  often  impossible. 
Salivation  is  frequently  a  prominent  symptom.  About  the 
eighth  or  ninth  day  the  pustule  attains  its  full  size,  and  the  stage 
of  suppuration  is  complete. 

Stage  of  Desiccation. — The  retrogade  changes  in  the  pustule* 
begin  on  the  face,  and  extend  in  from  two  to  four  days  to  the 
extremities.  These  changes  are  marked  in  some  of  the  pustules 
by  the  formation  of  a  brown  spot  in  the  center,  which  gradually 
extends  and  converts  the  pustule  into  a  hard  crust.  In  othera 
the  changes  are  announced  by  the  rupture  of  the  pustules,  the 
consequent  discharge  of  their  contents,  and  the  formation  of 
yellow  scabs.  Some  pustules  do  not  form  scabs,  but  shrink  away 
in  consequence  of  the  absorption  of  their  fluid  contents. 

As  desiccation  commences  the  areolaB  around  the  bases  of  the 
pustules  become  less  inflamed,  and  the  puffiness  of  the  face  dis- 
appears. The  secondary  fever  subsides,  the  temperature  of 
the  integuments  decreases,  and  the  pulse  diminishes  in  fre- 
quency. The  urine,  which  has  been  scanty,  high-colored  and 
perhaps  albuminous,  now  becomes  normal. 

The  drying  of  the  pustules  is  usually  completed  in  from  four 
to  seven  days. 

The  scabs  fall  off  between  the  eleventh  and  sixteenth  days.  In 
some  instances  they  leave  blotches  of  a  reddish-brown  color, 
which  remain  visible  for  five  or  six  weeks,  and  then  disappear 


■MB* 


CONFLUENT   SMALL-l'OX. 


339 


illy  formed,  maturing 
)o(ly,  ami  lastly  ou  tlu^ 
ration,  a  new  fever  to 
fever  is  applied,  makes 
y  a  distinct  chill,  nnil 
iperature  rapidly  rises 
imes  to  108°  Fahr.  or 
The  pulse  becomes 
and  140  beats  per  min- 
lirium  not  infrequently 
lat  the  features  are  no 
mes  tense,  hot  and  dry, 
lor.     In  the  vicinity  of 
I  painful;  each  pustule 
1  areola.    The  itching 
I  soreness  of  the  throat 
i\  and  often  impossible, 
symptom.      About  the 
3  full  size,  and  the  stago 

changes  in  the  pustules 

two  to  four  days  to  the 

in  some  of  the  pustules 

center,  which  gradually 

a  hard  crust.     In  others 

jure  of  the  pustules,  the 

8,  and  the  formation  of 

m  scabs,  but  shrink  away 

lir  fluid  contents. 

around  the  bases  of  the 

pufSness  of  the  face  dis- 

des,  the  temperature  of 

)ulse  diminishes  in  fre- 

jcanty,  high-colored  and 

aal. 

y  completed  in  from  four 

b  and  sixteenth  days.  In 
E  a  reddish-brown  color, 
eks,  and  then  disappear 


leaving  no  cicatrices.  In  other  cases,  usually  severe,  in  conse- 
mience  of  ulceraiion  and  destruction  of  the  cutis,  little,  dead- 
white,  cicatricial  "  pits  "  or  depressions  are  formed,  which  remain 
during  life,  and  give  to  the  face  a  "  pock-marked  "  appearance. 
During  convalescence  small  abscesses  frequently  form  on  the 

thighs  and  legs. 

The  desquamation  or  falling  of  the  crusts  ends  somewhei^ 
between  the  nineteenth  and  twenty-fifth,  and  even  the  fortieth 

days  of  the  eruption.  ^       / 

We  will  now  pass  on  to  the  consideration  of  the  conjiuent  va- 
riety of  the  disease. 

Confluent  Sinall-pox.-This  variety  of  small-pox  is  much 
more  severe  than  the  one  we  have  just  been  considering,  ihe 
stage  of  initial  fever  is  frequently  shortened  to  forty-eight  hours. 
The  temperature  often  reaches  106°  Fahr.  and  in  severe  types 
mav  rise  to  110°  Fahr.  The  skin  appears  inflamed  and  becomes 
swollen  and  of  darkish  hue.  On  the  second  day  numerous  red 
papules  seated  on  a  red  and  swollen  skin  appear  and  cover  all 
parts  of  the  body.  The  eruption  is  frequently  dark  and  livid, 
and  petechia  are  not  uncommon.  The  vesicles  as  they  form  in- 
crease the  violence  of  the  cutaneous  inflammation  and  are  so 
crowded  on  the  surface  that  their  edges  run  together.  The  pus- 
tules rapidly  follow  the  vesicles,  and  tend  to  coalesce  into  large 

flat  blebs.  .       ..      ,  i.        *„n„ 

After  the  appearance  of  the  eruption  the  temperature  falls 

slowly  to  103°  Fahr.  or  104°  Fahr.    With  suppuration  it  again 

rises  as  high,  and  in  some  cases  even  higher  than  during  the 

initial  stage.  .  ,. 

The  secondary  fever  is  much  more  dangerous  than  in  the  dis- 
tinct or  moderate  variety,  and  rapidly  assumes  a  typhoid  char- 

The  eruption  extends  to  the  mucous  lining  of  the  respiratory 
tract  in  severe  cases.  The  tongue  becomes  swollen  and  there  is 
great  difiiculty  in  swallowing.  Pharyngo-laryngitis  not  infre- 
quently  occurs.  Violent  and  persistent  vomiting  and  obstinate 
diarrhea  often  appear  with  the  initial  fever  and  continue  througli- 
out  the  disease.  Hemorrhage  may  take  place  from  the  mucous 
surfaces  of  the  alimentary  canal  and  urinary  tract.  Violent  de- 
lirium  is  of  common  occurrence,  and  not  infrequently  passes 
quite  suddenly  into  a  state  of  coma.    In  the  majority  of  cases 


,    -^w>  i."iiMlii<'*iiiii  ■■  »li*ift"i*'  '■  - 


840 


LECTURES  ON  FEVERS. 


albumen  appears  temporarily  in  the  urine.  Bronchitis,  pneumo- 
nin,  pericarditis,  pleuritis  and  acute  fatty  degeneration  of  thf* 
kidneys,  are  frequent  complications. 

In  the  stage  of  desiccation  large  concentric  crusts  are  formed 
over  the  confluent  patches,  while  suppuration  of  the  papillary 
layer  is  going  on  beneath.  After  the  crusts  have  fallen,  as  the 
cutis  is  more  or  less  extensively  destroyed,  ugly  pits  remain, 
often  producing  permanent  and  unsightly  disfigurements.  Per- 
manent loss  of  hair  not  infrequently  occurs. 

A  much  more  formidable  but  fortunately  rarer  variety  than 
cither  of  the  preceding  varieties  of  small-pox,  is  the  malignant 
or  hemorrhagic. 

Hemorrhagic  Small-Vox.— Hemorrhagic  or  Uack  small-pox 
is  extremely  rare,  although  cases  occur  in  every  epidemic.  The 
ushering-in  symptoms  are  occasionally  but  little  different  from 
those  of  the  preceding  varieties,  although  the  lumbar  pain  is  apt 
to  be  severe.  Frequently  the  initial  fever  is  extremely  violent, 
•while  during  the  rest  of  the  time  the  temperature  may  not  ex- 
ceed 102°  Fahr.  The  pulse  is  exceedingly  frequent  and  feeble 
from  the  start,  and  ranges  from  140  to  160  beats  per  minute. 

The  characteristic  papules  may  be  preceded  by  a  petechial  or 
roseolous  rash,  and  early  in  the  disease  the  eruption  assumes  a 
dark  color.  In  the  majority  of  cases  the  hemorrhagic  changes 
begin  in  the  papules  situated  upon  the  lower  extremities.  The 
vesicles  as  they  form  instead  of  filling  with  lymph,  contain  only 
a  thin,  sanguinolent  fluid.  They  are  irregular  in  shape,  and 
flabby.  They  mature  imperfectly  or  not  at  all,  and  seldom  reach 
the  suppurative  stage.  Petechias  and  ecchyraoses  form  between 
the  eruptive  points.  As  the  vesicles  or  pocks  break  or  are  rup- 
tured, dark  scabs  are  formed. 

The  cutaneous  surface  frequently  presents  a  dark,  purplish 
hue,  from  extensive  capillary  hemorrhages.  The  face  is  swollen, 
the  eyelids  are  thick  and  oedematous,  the  conjunctivae  are  blood- 
colored,  the  skin  is  ecchymotic  and  the  entire  features  are  oblit- 
erated. The  tongue  is  thickly  covered  with  a  white  fu^-,  and 
white  pustules  may  be  seen  on  the  fauces  and  palate.  Hemor- 
rhage from  the  mucous  surfaces  not  infrequently  occurs.  The 
mind  is  sometimes  clear,  delirium  is  common,  and  typhoid  stu- 
por may  exist 


'^'Siei»5i^\:vV.^v-^*i«.~.-f-**^ijj*;-ii^*«a»»i:;w^f«<s'fS'-^'**^fe«M^  ■■s>%(t,?a^iftij3irt^«fife^>**":-sojyi2>aMftf6?^*^ 


L 


ANALYSIS  OF  CHART. 


341 


Bronchitis,  pneumo- 
y  degeneration  of  tlu* 

trie  crusts  are  formed 
ntion  of  the  papillary 
sts  have  fallen,  as  tlie 
»d,  ugly  pits  remain, 
disfigurements.  Per- 
rs. 

tely  rarer  variety  than 
-pox,  is  the  malignant 

igic  or  black  small-pox 
every  epidemic.  The 
»ut  little  different  from 
the  lumbar  pain  is  apt 
r  is  extremely  violent, 
mperature  may  not  ex- 
y  frequent  and  feeble 
}  beats  per  minute, 
seded  by  a  petechial  or 
10  eruption  assumes  a 
hemorrhagic  changes 
wer  extremities.  The 
h  lymph,  contain  only 
regular  in  shape,  and 
t  all,  and  seldom  reach 
hyraoses  form  between 
)ocks  break  or  are  rup- 

isents  a  dark,  purplish 
s.  The  face  is  swollen, 
conjunctivae  are  blood- 
itire  features  are  oblit- 
with  a  white  fu^,  and 
1  and  palate.  Hemor- 
requently  occurs.  The 
imon,  and  typhoid  stu- 


Denth  generally  occurs  on  the  third  or  fourth  day;  occasion- 
ally it  hapi)en8  before  the  appearance  of  the  rash.  It  may  take 
place  fi-om  shock,  coma,  hemorrhagic  infarctions  of  the  lungs,  or 
rapid  exhaustion. 

Complications.— The  moat  important  complications  of  small- 
pox are,  inflammations  of  the  serous  membranes,  subcutaneous 
abscesses,  conjunctivitis,  otitis,  brcmchitis,  pneumonia,  acute 
fatty  degeneration  of  the  kidneys,  lesions  of  tlie  intestinal  canal, 
articular  inflammations  and  different  hemorrhages. 

Duration.— The  length  of  time  that  elapses  between  the  be- 
ginning of  the  initial  fever  and  the  termination  of  desquamation, 
varies  from  three  to  four  or  even  six  weeks. 

ANALYSIS  OF  CHABT. 

Tlie  Nervous  System.— C/iiH/ness  increasing  to  a  distinct 
chill  is  in  the  majority  of  cases  the  ushering-in  symptom  of 
small-pox. 

Headache  is  one  of  the  earlier  and  more  constant  attendants. 
It  is  commonly  confined  to  the  frontal  region,  but  may  extend 
over  the  entire  head. 

Vertiyo  is  often  associated  with  the  headache. 

Delirium  is  an  occasional  symptom.  It  is  apt  to  occur  in 
severe  cases,  and  is  generally  passive  in  character.  Occasionally 
it  is  active  or  maniacal. 

Coma  occurs  in  certain  proportion  of  fatal  cases.  ^ 

Pains  in  ihe  back  and  extremHies  are  prominent  diagnostic 
symptoms.  They  are  apt  to  be  intense  in  proportion  to  the  se- 
verity of  the  attack. 

Convulsions  frequently  attend  the  development  of  the  disease 
in  children. 

The  Special  Senses.— T/ie  j;?/^^.— Conjunctival  injection  is 
generally  present.  In  the  hemorrhagic  variety  the  conjunctiva 
is  blood-colored  and  (edematous.  Pustules  sometimes  form 
upon  the  conjunctiva  of  the  lids,  and  more  rarely  upon  that  of 
the  globe  or  upon  the  mucous  membrane  of  the  lachrymal  tract 
Keratitis,  and,  in  severe  cases,  deep  ulceration  of  the  cornea  are 
not  infrequently  observed.  Retinal  hemorrhages  occasionally 
occur  in  hemorrliagic  cases. 

Impairment  of  hearing,  and  even  complete  deafness,  not  un- 


JL 


842 


LECTURES  ON   FEVEB8. 

CHART  XlY.—SninlhPoj'. 


Nature: 


IiioubHtlou: 


StiiifOM : 


Duration: 


Eruption : 


Kosenla  vnrln- 
lOHa,  oc'casidM- 
Bly  on  si'conil 
duy. 


Temperature: 


Pulse: 


Nervous  System; 


Tongue: 


Digestive  Tract; 


Kespi  ration: 


Urine: 


Throat: 


Skin: 


Byes: 


Varieties: 


Mortality: 


Prophylactic : 


IliKhly  contHvious. 


Portnble. 


Ti'ii  to  tliirtfi-n  <l«yH. 


Initliil  Fever.  Eruptions.  Suppurution.         DesiiH'iltlon 


Throu  iluj-8. 


Istn.lM  D 


M 

R 

S 

0 

p 

2 

8 

100  to  140. 
Kull  frequent 


CnilMnuMS. 
Vertigo.  i-roH' 
tnl  heiidaehe. 
{'dill  ill  IiilMM. 


Red,  at  tip  and 
edges. 


Nausea.  Vom- 
iting. Abdom- 
inal pnins. 
Constipation. 


Labored. 


Scanty.   High- 
colored. 


Sore  throat 


Perspiration. 


Congested. 


rive  to  six  days. 


4lh,ll(licl 


i)  to  K  days. 


10  days  to  3  weekrt 


c 


Pustules  pea- 

slzi'd.    Maturf 

and  ruptui-o, 


(jmbillcateil 


First  on  face. 


Falls  2«  or  8» 


75  to  1(10. 


> 
K 
n 

r 

o 

9 

M 

o 

9 
"9 


Beddish  points. 

Inflamed. 

Dysphagia. 


InilRmed  areolae. 

Swollen. 

Sickly  odor. 


Conjunctivitis. 


105''  to  108" 

Secondary 

fever 


100  to  KM). 
Hard  iind  full 


Headache. 

Delirium. 

Coma. 


Thick,  white 
coating.  Sail 
vat  Ion. 


Constipation. 

Occasionally 

diarrhcea. 


Sbort&labored 


Albuminous. 
Casts. 


Whitish  points 

HI'ljr  intlamed 

Dysphagia. 

Tumefaction 
Sickly  odor. 


Keratitis. 
(Edema. 


.Scabs.  Crusts. 
Scales. 


Gradual  deollno. 


Profuse.     Pole. 


Returns  to  normal 


KeddlBh-brown 
blotches.     Cica- 
trices. 


Recovery. 


Distinct. 


Confluent. 


Hemorrhagic. 


Distinct,  3  to  3  percent.  Confluent,  SO  per  cent. 

Hemorrhagic,  always  fatal. 


Vaccination,  successfully  performed. 


Migtm 


mum^m 


■HBMi 


THE   ERUPTION. 


343 


or. 


Portable. 

layH. 

unit  inn. 

IH-Rlwatlon. 

A  dayx. 

10  days  to  3  weokr« 

iIps  pea- 
Mature 
riiptuif, 

.Scabs.  Crusts. 
Scales. 

tol08» 
onilary 
over 

Gradual  deoUno. 

to  HiO. 
iind  full. 

\ 

0 

1 
o; 

m 

i 

1 

Hdaebo. 
liriutn. 
oma. 

k,  whitf 
ngr.    Sali- 
Dtinn. 

tipation. 
sionally 
rrhcea. 

&labored 

iminouB. 
'asts. 

Profuse.     Pale. 

Ishpolnts 
intfamed 
ipimirta. 

Returns  to  normal 

ef action. 
Ely  odor. 

KeddlBli-brown 
blotches.     Cica- 
trices. 

ratitfs. 
aema. 

Recovery. 

HemorrtaaKic. 

onfluent,  SO  per  cent. 
ys  fatal. 

ly  performed. 

commonly  result  from  steiiosis  of  the  EuBtacliiau  tubes  iind 
catnviii  of  the  midtUe  ear,  coiiHequont  upon  tumidity  and  puru- 
lent infiltration  of  the  epithelium. 

The  Temperature.~The  fever  in  small-pox  is  of  the  relaps- 
inc  type  The  temperature  in  the  initial  fever  rises  rapidly  in 
an  unbroken  line  to  104^  Fahr.  on  the  first  day.  During  the 
second  day  it  may  rise  to  10.5°  Fahr.,  and  by  the  third  day  it  may 
reach  106°  Fahr.  or  even  107°  Fahr.  After  the  papules  appear 
the  temperature  falls  more  or  less  rapidly,  from  the  second  to 
the  sixth  day  of  the  eruptive  period.  Occasionally  it  reaches 
the  normal,  but  generally  it  remains  sub-f(  brile.  During  the 
suppurative  fever  it  rises  again  to  a  height  commensurate  with 
the  severity  of  the  case.  In  confluent  cases  the  secondary  fever 
is  marked  by  higher  temperature  and  more  active  delirium  than 
in  distinct  or  moderate  forms. 

In  non-fatal  cases  the  secondary  fever  lasts  about  a  week,  or 
until  many  of  the  pustules  burst  or  dry  into  scabs  and  crusts, 
and  defervesces  by  gradual  lysis. 

The  Pulse.— The  pulse  is  increased  in  frequency  durinfr  the 
initial  fever,  and  ranges  from  100  to  140  beats  per  minute.  It 
diminishes  fifteen  or  twenty  treats  during  the  eruptive  stage,  but 
rises  again  to  120  or  140,  or  even  160  during  the  suppurative 
stage.     With  defervescence  it  slowly  returns  to  the  normal. 

In  severe  confluent  cases  the  heart -sounds  are  sometimes  feeble 
and  obscure,  and  the  heart's  action  irregular  and  intermittent. 
Pericarditis  occasionally  occurs  in  conjunction  with  pleurisy. 
Ulcerative  endocarditis  is  rare. 

The  Respiratory  System.— The  respiratory  movements  are 
generally  accelerated,  and  dyspnoea  is  often  marked.  Bronchitis 
is  common  in  all  well-marked  cases.  Catarrhal  pneumonia  may 
supervene  upon  bronchitis,  and  in  persons  predisposed  to  it, 
phthisis  may  be  derveloped.  Croupous  pneumonia  may  occur 
during  any  period  of  the  eruptive  stage.  Pleurisy  setting  iu 
suddenly,  and  displaying  a  tendency  to  result  in  empyema,  is  not 
uncommon  after  the  twelfth  day  in  severe  cases. 

The  Eruption.— The  eruption  of  small  pox  appears,  as  a  rule, 
on  the  third  day,  exceptionally  it  is  met  with  as  early  as  the  sec- 
ond or  not  discovered  until  as  late  as  the  fifth,  sixth,  or  even  the 


I' 


sa 


LECTURES  ON  FEVUIIH. 


seventh  dny.  It  in  characteristic  of  the  dinenHe,  and  in  first  soeii 
upon  the  face,  especially  along  the  edges  of  the  hair  and  ahout 
the  chin  and  mouth.  It  soon  extends  to  the  neck,  triink  and  ex- 
tremities, and  within  twenty-four  or  forty-eight  lioxuw  the  entire 
body  may  be  more  or  less  covered  by  it.  In  young  children  it  in 
often  first  observed  n\)oti  the  genitals. 

An  intimate  relaticm  exists  between  the  abundance  of  the 
eruption  and  the  severity  of  the  disease.  A  copious  eruption, 
deej)  in  color,  and  early  becoming  liviil  or  petechial,  indicates,  ns 
a  rule,  a  severe  attack.  Sometimes  n  voseolous  rash  resembling 
measles  precedes  the  characteristic  eruption.  In  confluent  cases 
the  eruption  is  dark  and  livid,  and  petechite  are  common. 

The  course  of  the  small-pox  eruption  is  as  follows:  At  first 
the  lesion  consists  of  small,  isolated  and  rounded  upecks,  which 
soon  become  converted  into  papules.  The  papules  are  of  a  vivid 
red  color,  and  meosure  from  a  third  to  two-thirds  of  a  line  in 
diameter.  They  are  hard  and  feel  like  shot  under  the  skin,  and 
are  frequently  arranged  in  three's  and  five's  in  a  crescentic  man- 
ner. In  hemorrhagic  oases  bright-red  i>etechi(B  occur  ui>on  the 
skin,  coincident  with  tlie  appearance  of  the  papules.  On  the 
third  doy  of  the  eruption  the  papules  become  conical  in  shape, 
and  the  apex  of  each  pimple  becomes  vesicular,  and  gradually 
as  the  whole  pimple  takes  this  character,  the  apex  becomes  de- 
pressed, till  on  the  fourth  or  fifth  day  of  the  eruption  an  nmhil- 
icuh'd  vesicle  is  formed,  containing  a  clear  fluid  and  surrounded 
by  tt  narrow,  rosy  areola.  In  confluent  cases  the  vesicles  as  they 
form  upon  the  papules,  so  crowd  the  surface  as  to  run  together, 
and,  instead  of  serum,  often  contain  a  thin,  brownish,  ichorous 
fluid.  In  hemorrhagic  cases  they  fill  with  a  thin,  sanguinoleut 
fluid,  instead  of  serum,  and  remain  flat  and  flabby. 

The  contents  of  the  vesicle,  which  are  at  first  transparent, 
gi'adually  become  whitish  and  milky,  and  by  the  sixth  or  seventh 
day  they  appear  as  pus — the  vesicle  is  now  transformed  into  a 
pustule.  This  process  begins,  as  in  all  the  metamorphoses  of 
the  disease,  in  vesicles  of  greatest  age,  those  namely  on  the  face 
and  upper  part  of  the  body.  As  a  general  rule,  the  pocks  are 
most  numerous  on  the  face,  and  next  on  the  neck  and  limbs. 

The  pustules  enlarge  until  they  attain  the  size  of  a  pea,  and 
the  umbihcation  becomes  lost.  Their  bases  become  hard  and 
more  or  less  broadened,  and  the  whole  of  the  skin,  especially 


isense,  nnd  in  first  seen 
of  tho  Imir  aiul  ulxmt 
ho  neck,  trunk  and  ox- 
•oight  JiouiH  tlio  entiro 
[n  youiiy  children  it  ia 

;he  nbundanco  of  the 
A  copiouH  eruption, 
)etecliial,  indicates,  as 
)louH  rasii  resembling 
u.     Ill  confluent  cases 
U3  are  common. 
i  as  follows:    At  first 
junded  specks,  which 
tapulcs  are  of  a  vivid 
'o-thirds  of  a  line  in 
t  under  the  skin,  and 

ill  n  crescentic  man- 
chire  occur  ujion  the 
ie  papules.    On  the 
me  conical  in  shape, 
ulnr,  and  gradually 
he  apex  becomes  de- 
9  eruption  an  umbiL 
luid  and  surrounded 
1  the  vesicles  as  they 
>  as  to  run  together, 
brownish,  ichorous 

thin,  sanguinolent 
Babby. 

it  first  transparent, 
the  sixth  or  seventh 
transformed  into  a 
metamorphoses  of 
namely  on  the  face 
rule,  the  pocks  are 
leck  and  limbs. 
e  size  of  a  pea,  and 
8  become  hard  and 
le  skin,  especially 


THE  Tnno.vT. 


345 


about  the  face,  liecomes  red  nnd  tumefied.  About  the  eighth  or 
ninth  day  of  the  eruption  tho  pustul'^s  either  break  and  diHclifirgo 
their  contents,  which  harden  into  yellowish  and  ultimately 
brownish,  irregular  crusts,  or  else  the  entire  envelope  and  con- 
tents desiccate  and  ff)rm  brownisti  scabs. 

After  a  variable  jieriod  of  from  a  few  days  to  five  or  six  weeks, 
the  criiats  fall  and  leave  a  depressed,  leddisii-brown  stain,  which 
in  time  (five  or  six  weeks)  (lisappear.  If  there  has  been  much 
destruction  of  the  cutis,  whitish  depressed  xcars  called  "pitw" 
are  formed,  and  the  skin  presents  a  "  ])ock-marked  "  apiiearance. 

The  Throat.— An  eruption  ajipears  ujion  the  pharyngeal,  buc- 
cal, nasal,  conjunctival  and  genital  mucous  membranes,  simulta- 
neously with  or  slightly  preceding  the  eruption  on  the  skin.  It 
begins  with  more  or  less  vivid  redness  of  the  mucous  membrane, 
followed  by  development  of  little  red  elevations.  On  the  second 
or  third  day  these  red  elevations  assume  the  appearance  of  whit- 
ish, rounded  jioints,  which  last  generally  alK)ut  five  days. 

Soon  after  the  appearance  of  pustules  in  the  mouth  and  throat, 
a  true  inflammation  of  the  parts,  as  indicated  by  more  or  less 
sore  throat  and  difficulty  in  swallowing,  with  swelling  and  ten- 
derness of  sub-maxillary  glands,  sets  in.  Occasionally  if  the 
eruption  extends  to  the  larynx  there  is  laryngeal  distress  and 
hoarseness. 

The  Skin.— After  the  appearance  of  the  eruption  the  skin 
becomes  tense,  red  and  shining,  and  there  is  more  or  less  inflam- 
mation and  swelling  of  the  sub-cutaneous  cellular  tissue.  The 
swelling  is  greatest  upon  the  face,  where  it  commences  about  the 
fourth  or  fifth  day  of  the  eruption,  increases  for  five  or  six  days 
and  then  gradually  diminishes  as  desiccation  begins.  In  severe 
confluent  cases  the  skin  becomes  thickened,  swollen  and  hard, 
and  assumes  a  darkish  tint.  And  in  hemorrhagic  cases  the  face 
is  swollen,  purple  or  black,  and  bloody  extravasations,  which 
frequently  dissect  the  cuticle  from  the  skin,  take  place  beneath 
the  eruptive  jjoints. 

The  physiognomy  of  a  person  ill  with  small-pox  is  somewhat 
peculiar.  The  tumid  and  closed  lids,  and  the  oedematous  face 
thickly  covered  with  pustules,  render  the  features  absolutely 
indistinguishable. 

The  Digestive  Tract.— The  tongue  is  generally  moist  and 


:0r- 


n 


R(f] 


LECTUnEH  ON   FFA'F.HS. 


more  or  Iohb  fuiTPd,  niid  in  rod  nt  tlic  tip  niul  PilgOB.  In  conflu. 
piit  cuseH  it  iw  frequontly  «'iiliirjj('(l. 

Tlio  (ii>i)rfHv  in.  im  u  rulo,  lost  <luriiifi;  tlm  conrHo  of  tlio  fovor. 
SoiiictiiiioH  it  r<>turiiH  toinponirily  during?  tlio  ntn^^o  of  (Muptions. 

Thivxt  is  coiinnoidy  proseiit,  nnd  is  ntfute  in  i)roportion  to  the 
viol»Mn-o  of  tli(>  fever. 

Xniisfd  and  voinifiiif/  occur  in  the  onrly  stagps,  and  are  apt  to 
\w  |)r<iniinent  HymptoniH. 

J)iisi)h(ui{(i  occurs  in  moHt  casoH,  and  is  usually  most  marked 
in  continent  ciihob. 

Const iiHii ion  is  very  common  in  small-pox,  and  generally  con- 
tinues througliout  the  disease.  A  slight  diarrhea  occasionally 
makes  its  appearance  about  the  end  of  the  first  or  second  week. 
A  severe  diarrhea  is  almost  always  the  sign  of  a  dangerous  com- 
plication. Colicky  pains  referred  to  the  epigastric  region  are 
often  complained  of. 

The  Urine.— Tlie  urine  is  diminished  in  quantity  during  the 
initial  fever.  After  the  secondary  fever  it  is  increased  in  quan- 
tity and  of  low  specific  gravity.  Its  color  is  at  first  darker  than 
in  health;  during  desiccation  it  is  pale.  Urea  and  uric  acid  are 
increased,  and  the  chlorides  are  gradually  diminished.  In  many 
cases  albumen  and  tube-casts  are  present.  HoBmaturia  is  occa- 
sionally encountered,  and  is  always  a  grave  symptom.  It  is 
commonly  associated  with  other  hemorrhages. 

The  Genital  Organs. — In  non-pregnant  females  premature 
mensiruaiion  is  apt  to  occur.  • 

In  pregnant  women  there  is  a  great  tendency  to  abort,  es- 
pecially in  the  latter  months  of  pregnancy. 

In  men  variolous  orchitis  is  not  uncommon. 


In  conflu- 


imrHO  of  tho  fovor. 
Htn^o  of  oruptionH. 
I  i)r()portion  to  the 

geg,  nnd  nre  apt  to 

tinlly  moBt  marked 

and  generally  con- 
irrhen  occasionally 
rflt  or  second  week. 
:  ft  dangerous  cora- 
igastric  region  are 

uantity  during  the 
increased  in  quan- 
it  first  darker  than 
a  and  uric  acid  are 
linished.  In  many 
loBmaturia  is  occa- 
3  symptom.  It  is 
1. 

emales  premature 
lency  to  abort,  es- 


LECTITRE    XXII. 

SinalUroX.- (Continued.) 

At  my  last  lecture  I  spoke  of  the  nature,  cftusation  and  course 
of  miall-pox.  To-diiy  1  proiiose  to  complete  its  hintory  by  con- 
sidering  its  anatomical  changes,  differential  diagnosis  and  treat- 
ment. 

Morbid  Anatomy.— The  charncteristic  lesion  of  small-pox  is 
the  inflammation  of  the  skin  and  mucous  membrane  constituting 

the  eruptioiu  .    .  ., 

The  red  spot  which  is  the  first  step  in  the  development  of  the 
eruption,  is  due  to  localized  hypenemia  of  the  papillary  body. 
Soon  the  papillre,  which  are  the  seat  of  the  congestion,  become 
surrounded  with  cells,  usually  of  larger  size  than  those  of  nor- 
mal  tissue.  Most  of  these  cells  are  swollen  epithelia  from  the 
rete,  that  have  undergone  coarse  granulation  as  a  result  of  the 
hyperteraia.  The  chief  collections  of  these  elements  are  seated 
mostly  in  the  neighborhood  of  a  hair  follicle  or  sweat  gland. 
As  they  accumulate  they  elevate  the  epidermis,  and  a  little  pa- 
pule appears  at  the  point  of  redn<*ss.  The  papules  which  are 
formed  at  the  red  spot  are  thus  due  mainly  to  the  changes  in  the 
rete  Malpighii  and  in  the  capillaries. 

Following  these  changes  an  exudation,  in  which  there  are 
suspended  delicate  granules  of  coagulated  albumen,  and  irregu- 
lar  threads  of  coagulated  fibrin,  makes  its  appearance  in  an 
irregular  cavity  in  the  midst  of  the  greatly  widened  rete,  result- 
ing from  destruction  of  the  epithelia.  As  the  exudation  increases, 
a  little  vesicle  is  formed  upon  the  summit  of  the  papule. 
Frequently  within  a  brief  period  after  the  first  appearance  of 

(347) 


348 


LECTl'UES  ON  FEV'ERS. 


the  vesicle,  its  centei'  becomes  dejjressed.  This  depression  or 
umhili'cdtioii  is  supposed  to  be  due  to  the  more  rnpid  swelling  of 
the  peripheral  cells.  It  is  not  observed  in  every  vesicle,  and  dis- 
appears, as  n,  rule,  at  the  stage  of  suppuration. 

As  soon  as  the  vesicles  are  fully  formed,  pus-corpuscles.arising 
by  endogenous  formation  from  the  ei)ithelia  traversing  and 
bounding  the  cavity  formeil  in  the  rete,  appear.  The  vesicles 
are  now  changed  to  pustules.  In  healthy  individuals  the  pus  is 
thick  and  yellow,  and  the  pus-corpuscles  appear  coarsely  giaa- 
ular;  while  in  weakly,  scrofulous  persons  the  pus  is  watery  and 
pale,  and  the  pus-corpuscles  are  finely  granular. 

The  pustules  as  soon  as  they  have  matured,  either  burst  or 
their  contents  dry,  and  form  crusts.  During  desiccation  on  ac- 
count of  the  drying  of  the  center,  before  the  periphery  of  the 
pustule,  a  depression  known  as  the  umbilication  of  desiccation, 
often  forms,  at  times  in  pocks  previously  non-umbilicated.  If  the 
suppuration  has  been  the  result  solely  of  the  destruction  of  the 
epithelia,  no  scar  will  be  formed.  But  if  a  part  of  the  connect- 
ive tissue  has  been  transformed  into  pus,  the  result  will  be  a 
cicatrix  and  pitting. 

The  pigmentation  of  the  skin  which  remains  after  the  scabs 
have  fallen,  is  due  to  imbibition  of  the  coloring  matter  of  the  red 
blood-corpuscles  which  have  transuded  from  the  capillary  loops 
in  the  pnpillfe. 

On  the  mucous  membrane  the  eruption  is  thickest  and  deepest 
in  the  respiratory  tracts. 

The  blood  is  of  a  dark  color  and  deficient  in  fibrin. 

Congestion  and  parenchymatous  changes,  consisting  of  granu- 
lar or  fatty  infiltration  of  the  internal  organs  are  frequently 
observed. 

Extvavasaiions  of  blood  are  found  in  almost  all  of  the  viscera, 
and  in  the  skin  and  mucous  membrane,  in  hemorrhagic  cases. 

Differential  Diagnosis. — The  diagnosis  of  small-pox  should 
be  made  out  as  early  as  possible,  so  that  persons  in  contact  with 
the  patient  may  be  vaccinated  or  re- vaccinated  in  time  to  prevent 
the  diifusion  of  the  disease.  To  be  effective  vaccination  must 
be  performed  in  time  to  reach  the  stage  of  areola — from  seven 
to  nine  days — before  any  illness  from  small-pox  occurs. 

As  a  rule,  the  diagnosis  cannc.>  be  made  with  certainty  pre- 
vious to  the  stage  of  eruption,  and  even  then  there  is  a  possibility 


I<1.  This  depression  or 
more  mind  swelling  of 
|i  every  vesicle,  nnd  dis- 
ation. 

L  pus-corpuscles.nrising 
tlielin  traversing  and 
appear.  The  vesicles 
>■  individuals  the  pus  is 
appear  coarsely  giaii- 
the  pus  is  watery  and 
nular. 

fvtured,  either  burst  or 
I'ing  desiccation  on  nc- 
the  periphery  of  the 
lication  of  desiccation, 
on-umbilicated.  If  the 
the  destruction  of  the 
f  a  part  of  the  connect- 
us,  the  result  will  be  a 

mains  after  the  scabs 

oring  matter  of  the  red 
lom  the  capillary  loops 

is  thickest  and  deepest 

nt  in  fibrin. 

's,  consisting  of  granu- 

)rgans  are  frequently 

most  all  of  the  viscera, 
I  hemorrhagic  cases. 

s  of  small-pox  should 
ersons  in  contact  with 
ated  in  time  to  prevent 
;ive  vaccination  must 
f  areola— from  seven 
ll-pox  occurs. 

0  with   certainty  pre- 

1  there  is  a  possibility 


DIFFEKENTIAL  DIAGNOSIS. 


349 


of  mistake.  Generally,  your  safest  course  will  be  not  to  commit 
yourselves  to  a  positive  diagnosis  until  the  vesicles  are  fully 
formed,  up  to  which  time  there  is  but  little  danger  from  infec- 
tion. 

The  principal  diagnostic  points  are:  the  prominence  of  lum- 
bar pains  and  vomiting,  the  remission  or  cessation  of  fever  as 
the  eruption  appears,  the  appearance  of  the  eruption  on  the 
third  day  and  first  upon  the  forehead  along  the  margin  of  the 
hair,  the  granular,  hard,  shotty  papules,  the  umbilication  of 
the  vesicles,  and  the  round,  whitish  or  ashy  spots  on  the  throat 
and  mouth. 

In  the  initial  stage  it  is  possible  to  mistake  small-pox  for  ty- 
phus fever  or  meningitis.  And  during  the  first  forty-eight  hours 
the  roseolous  rash  if  present  may  be  mistaken  for  scarlet  fever 
or  roseola.  On  the  third  day,  when  the  papular  rash  is  appear- 
ing, it  ID  ay  be  mistaken  for  either  measles,  german  measles  or 
acne.  At  a  later  stage  when  the  vesicles  form  it  is  possible  to 
mistake  it  for  varicella  or  chicken  pox. 

Typhus  fever  can  be  easily  differentiated  from  small-pox  after 
the  advent  of  the  eruption.  In  small-pox  the  eruption  makes 
its  appearance  upon  the  third  day,  while  in  typhus  it  does  not 
appear  until  the  fifth  day,  and  is  first  seen  upon  the  abdomen. 

Meningitis  often  simulates  small-pox  in  the  initial  stage,  as 
both  diseases  have  photophobia,  intense  headache,  nausea  and 
vomiting  occurring  as  prominent  symptoms.  In  meningitis, 
however,  the  face  is  generally  pale  and  anxious,  while  in  small- 
pox it  is  flushed.  The  advent  of  the  eruption  will  always  dispel 
any  doubt  as  to  the  correct  diagnosis. 

Acne  is  always  distinguished  by  the  absence  of  the  special 
constitutional  symptoms  of  small-pox. 

Measles  may  be  differentiated  from  small-pox  by  the  early 
presence  of  catarrhal  symptoms  and  by  the  absence  of  well- 
marked  lumbar  pain.  The  papules  appear  on  the  third  day  in 
small-pox  and  are,  small,  hard  and  distinct.  They  appear  on  the 
fourth  day  in  measl°is,  and  are  larger  and  flatter,  and  soon  run 
together  in  crescentic  outlines.  In  small-pox  the  temperature 
falls  as  the  stage  of  eruption  is  reached,  while  in  measles  it  con- 
tinues to  rise  as  the  eruption  appears. 

Varicella  or  chicken-pox  differs  from  small-pox  in  the  almort 
complete  absence  of  prodromes  and  in  the  rapid  course  of  the 


a[50 


LECTURES  ON  FEVERS. 


eruption.  The  rash  appears  on  the  second  day,  shows  itself  at 
once  upon  the  face  and  trunk,  and  in  a  few  hours  becomes  xes- 
icular.  The  vesicles  are  usually  small,  oval  and  remarkably 
transparent,  and  are  apt  to  appear  in  successive  crops. 

Prognosis.— The  prognosis  will  depend  largely  upon  the 
amount  of  the  rash,  for  other  things  being  equal,  the  more  ahtin- 
dant  ihe  ernpiimi,  ihc  greater  the  danger. 

The  distinct  variety  is  not  usually  fatal  unless  some  complica- 
tion  arises,  the  moi-tality  being  about  two  or  three  per  cent  among 
the  non-vaccinated.  In  semi-confluent  small-pox  the  mortality 
is  about  six  per  cent.  In  the  confluent  variety  nearly  one-half 
of  the  cases  die.    The  hemorrhagic  form  is  always  fatal. 

The  prognosis  is  greatly  influenced  by  age.     In  early  infancy 
and  in  old  age,  the  ratio  of  mortality  reaches  its  maximum.     In 
intemperate  people  and  in  the  over-worked  and  badly  nourished, 
the  prognosis  is  bad.     Women,  pregnant  or  in  the  puerperal 
state  and  all  persons  unprotected  by  previous  vaccination,  run 
great  risk  when  taken  ill  with  small-pox.     As  in  other  epidemics, 
the  mortality  is  greatest  at  the  beginning  and  height  of  the  epi- 
demic, and  gradually  declines  as  the  latter  draws  to  a  close. 
Small-pox  is,  as  a  rule,  more  fatal  in  summer  than  in  winter. 
Death  is  sometimes  attributable  to  the  intensity  of  the  fever. 
Usually,  if  death  occurs  before  the  suppurative  stage  is  reached, 
it  is  due  to  some  complication  involving,  in  the  majority  of  cases, 
the  throat  and  air  passages. 

When  not  attributable  to  complications,  a  fatal  termination  is 
generally  due  to  inability  of  the  powers  of  the  system  to  with- 
stand the  depressing  influence  of  the  suppurative  process.  If 
death  does  not  occur  until  the  second  week,  it  is  oftenest  due  to 
exhaustion. 

The  most  dangerous  complication  of  small-pox  at  the  suppur- 
ative stage,  is  acute  fatty  degeneration  of  the  kidneys. 

Unfavorable  prognostics  are,  occurrence  of  the  disease  at  the 
extremes  of  life,  violent  nervous  symptoms  during  the  initial 
stage,  abundance  of  eruption,  continuation  of  fever  after  appear- 
ance of  eruption,  occurrence  of  petechiee  and  local  hemorrhages 
cessation  of  salivation,  typhoid  delirium  and  other  ataxic  symp- 
toms. 
TreAtmeni.— Prophylaxis.— The   preventive   treatment   of 


1 


PROPHYLAXIS. 


351 


ay,  shows  itself  at 
ours  becomes  ves- 
1  and  remarkably 
ve  crops. 

largely  tipon  the 
lal,  the  more  ahun- 

3S8  some  complica- 
ree  per  cent  among 
l-pox  the  mortality 
ety  nearly  one-half 
hvays  fatal. 

In  early  infancy 
its  maximum.  In 
id  badly  nourished,, 
r  in  the  puerperal 
IS  vaccination,  run 
in  other  epidemics,^ 
I  height  of  the  epi- 
r  draws  to  a  close» 
:  than  in  winter, 
ensity  of  the  fever, 
ive  stage  is  reached^ 
le  majority  of  cases, 

fatal  termination  is 
the  system  to  with- 
irative  process.  If 
it  is  oftenest  due  to 

l-pox  at  the  suppur- 
le  kidneys. 
}f  the  disease  at  the 
s  during  the  initial 
if  fever  after  appear- 
i  local  hemorrhages 
d  other  ataxic  symp- 

mtive   treatment   of 


small-pox  consists  in  vaocinaiion,  properly  performed,  and  of 
which  I  shall  speak  at  my  next  lecture.  Should  your  patient 
consult  you  too  late  to  expect  results  from  vaccinfrtion,  you  may 
administer  either  malandrinum  or  vaccinimm  internally  as  a 
prophylactic,  usually  with  marked  success.  Drs.  Eaue  and 
Straube  speak  highly  of  the  effect  of  malandrinum  in  the  PiuJ- 
adelphia  epidemic  of  1880-81,  and  Drs.  Kaczkowsky,  Landel  , 
Hughes  and  others  concur  in  testifying  to  the  great  value  of  \ac- 
cininum.  Baptisia,  hydrastis,  tartar  emetic,  sarracenia,  cimici- 
fuga  and  sulphur,  each  and  all  have  advocates  of  their  prophy- 
lactic virtues  in  small-pox. 

To  prevent  the  spread  of  the  disease,  every  small-pox*  patient, 
unless  he  can  be  thoroughly  isolated  at  home,  should  be  com- 
pelled to  go  to  the  municipal  small-pox  hospital.  Every  city 
and  large  town  should  have  its  small-pox  hospital— built  after 
the  barrack  system— particularly  when  the  disease  is  prevailing 
as  an  epidemic. 

Every  one  in  the  house  with  the  sick  person  should  be  vaccin- 
ated or  re-vaccinated.  The  patient  should  be  removed  to  an 
upper  room,  as  far  from  other  living  and  sleeping  rooms  as  pos- 
sible, and  absolutely  no  one  should  have  access  to  him  or  her, 
except  the  physician  and  the  nurse  The  sick  room  should  be 
large— noi  less  than  fifteen  hundred  cubic  feet— and  well  venti- 
lated, and  the  temperature  should  be  kept  below  60"  Fahr.  All 
unnecessary  furniture,  and  all  curtains  and  hangings  which  are 
liable  to  interfere  with  ventilation  or  retain  the  contagion  should 
be  removed  from  the  room.  Sheets  should  be  hung  up  in  the 
door  and  window  ways,  which  should  be  kept  constantly  saturated 
with  Piatt's  chlorides  or  some  disinfecting  solution.  Absolutely 
no  intercourse  should  be  had  by  the  nurse  with  the  members  of 
the  family  and  the  outside  world,  until  all  danger  of  contagion 
has  passed. 

Inmates  of  the  house  during  the  continuance  of  the  disease, 
should  refrain  from  visiting  any  school,  church,  theatre  or  other 
place  of  public  assemblage.     All  letters  before  being  sent  from 
the  house  should  be  put  in  an  oven  and  subjected  to  a  temper^ 
ature  of  not  less  than  250°  Fahr. 

*  All  cases  of  small-pox  odcurring  in  the  connty,  must  be  reported  to  the 
County  Clerk;  or,  in  cities,  to  the  City  Board  of  Health. 


^52 


LECTURES  ON  FEVERS. 


When  attending  a  small-pox  case,  before  entering  the  sick 
room,  you  should  remove  your  overcoat  and  put  on  a  rubber 
coat,  which  nJust  be  sponged  with  a  weak  carbolic  acid  solution, 
and  hung  up  in  another  room  on  leaving  the  apartment.  Before 
visiting  your  next  patient  it  would  be  well  to  take  a  short  drive 
in  the  open  air. 

Piatt's  chlorides  or  a  potassium  cyanide  solution  (ten  grains 
to  the  ounce  of  water),  should  be  sprinkled  upon  the  bed  and 
about  the  room. 

All  discharges  from  the  nose  and  mouth  should  be  received  on 
cloths  and  immediately  burned.  The  urine  and  faeces,  and  any 
scabs  that  may  fall  from  the  body,  should  be  received  in  vessels 
partly  filled  with  either  a  five  per  cent  solution  of  carbolic  acid 
or  some  other  disinfectant,  and  afterwards  buried  a  sufficient 
distance  from  the  water  supply.  All  bed  and  body  linen  should 
be  thoroughly  washed  in  a  disinfecting  solution  before  being 
removed  from  the  room,  and  afterwards  baked. 

After  recovery  the  patient  should  be  bathed  in  Piatt's  chlorides 
solution,  or  in  a  weak  solution  of  chloride  of  zinc — one  part  to 
three  hundred — and  fresh  clean  clothing  put  on.  And  at  least 
two  weeks  should  elapse  after  desquamation  has  taken  place, 
before  he  may  be  allowed  to  again  enjoy  the  society  of  his  fam- 
ily and  friends.  In  the  event  of  death  the  clothing  of  the  de- 
ceased should  be  sprinkled  with  strong  carbolic  acid,  the  body 
placed  in  an  air-tight  coffin,  and  privately  interred,  as  early  as 
possible. 

After  recovery  or  death,  the  apartment  should  be  fumigated 
by  burning  sulphur,  thoroughly  aired,  cleansed  and  whitewashed. 
The  bedding,  iill  articles  worn  by  the  patient,  and  all  the  wear- 
ing apparel  used  by  the  nurse,  should  be  either  baked  or  if  pos- 
sible immersed  in  some  disinfecting  fluid  and  then  thoroughly 
boiled.     The  mattrass  and  pillows  should  be  burned. 

Principal  Remedies. — Baptisia,  belladonna  and  veratrum  vir. 
are  oftenest  indicated  in  the  initial  stage;  vaccininum,  malan' 
drimim,  iartar  emet.  and  thuja  in  the  stage  of  eruptions;  mercu- 
rius,  malandrinum  and  lachesis  in  the  suppurative  stage;  and 
fiulphur  in  the  stage  of  desiccation. 

Baptisia  will  be  needed  during  the  initial  fever  when  there  is 
considerable  prostration,  and  an  early  tendency  to  decomposition. 
Veratrum  vir.  is  called  for  when  the  fever  is  intense,  the  pain 


PRINCirAL  nEMEDIES. 


entering  the  sick 
1  put  on  a  rubber 
olic  acid  solution, 
partment.  Before 
take  a  short  drive 

lution  (ten  grains 
ipon  the  bed  and 

uld  be  received  on 
md  faeces,  and  any 
'eceived  in  vessels 
n  of  carbolic  acid 
buried  a  suflScient 
body  linen  should 
ion  before  being 

n  Piatt's  chlorides 
zinc — one  part  to 
on.  And  at  least 
has  taken  place, 
Dciety  of  his  fam- 
lothing  of  the  de- 
)lic  acid,  the  body 
erred,  as  early  as 

luld  be  fumigated 
and  whitewashed, 
and  all  the  wear- 
r  baked  or  if  pos- 
i  then  thoroughly 
irned. 

and  veratrum  vir. 
ccininum,  malan- 
eruptions;  mercu- 
rative  stage;  and 

ver  when  there  is 
to  decomposition, 
intense,  the  pain 


in  the  back  is  severe,  and  the  pulse  is  very  rapid.  Cimirifntja 
should  be  thought  of  when  the  headache  and  backache  uie  se- 
vere, and  there  is  nausea  and  restlessness.  Bdtadanna  will  be 
of  service  when  the  head  and  throat  symptoms  are  severe,  and 
there  is  a  tendency  to  delirium. 

Tartar  emvt.  is  specially  valuable  during  the  eruptive  stage. 
It  is  also  of  service  during  the  stage  of  initial  fever,  if  nausea 
and  vomiting  are  very  troublesome.  After  bnjmia,  it  is  the 
remedy  for  early  bronchitis.  Mercurius  will  have  a  favorable 
effect  upon  the  suppurative  process,  if  administered  as  soon  as 
the  secondary  fever  appears.  It  is  always  indicated  when  such 
symptoms  as  salivation,  ulcerated  sore  throat,  foetid  breath  and 
bloody  diarrhea  are  present.  Arsenicum  iodide  is  preferable  to 
either  mercurius  or  tartar  emet.,  after  the  pustules  are  formed, 
and  there  is  a  tendency  to  putrid  decomposition.  Apis  will  be 
of  service  when  there  is  excessive  swelling  of  the  face  with 
troublesome  itching,  and  when  either  cedema  of  the  glottis  or 
nephritis  threatens.  Camphor,  if  the  eruption  suddenly  disap- 
pears  or  suddenly  becomes  malignant.  Lachesis  or  rhus  tox.,  if 
a  typhoid  condition  attains  during  the  suppurative  stage.  i»f u- 
riatic  acid  or  variolinum  for  malignant  throat  symptoms. 
Hepar  sulph.  for  croupous  laryngeal  symptoms  during  the  sup- 
purative stage,  and  for  boils  during  the  stage  of  desiccation. 
Mercurius  cor.  for  the  ophthalmia,  and  after  apis  for  the  paren- 
chymatous nephritis.  Bryonia  and  kali  Mch.  for  bronchitis. 
Phosphorus  or  tartar  emet.  for  pneumonic  complications. 
Sulphur  when  there  is  furious  itching  during  desquamation. 
Kali  sulph.  to  hasten  the  removal  of  the  scabs.  Cinchona  for 
excessive  debility  and  prostration  after  a  severe  attack. 

Malandrinum,  tartar  emet.,  arsenicum  and  phos.  acid  are  often- 
est  used  in  confluent  cases.  Crotalus,  ammonium  carb.  and 
lachesis  are  the  remedies  most  frequently  administered  m  the 
hemorrhagic  variety. 

Leading  Indications.— The  guiding  symptoms  for  the  differ- 
ent  remedies  may  be  compiled  as  follows: 

Ammonium  carb.— Hemorrhagic  tendency.  Putrid  sore 
throat  {7nur.  acid).  Dyspnoea  from  retrocession  of  eruption. 
Adynamia. 

Apis  mel.— High  fever  with  chilliness  from  the  slightest 


Ul»)ll>iMi*»»«WtPWUIIW 


t 


854 


LECTURES  ON   FEVERS. 


movement.  Erysipelatous  redness  and  swelling  with  stinging, 
burning  pains  in  skin  and  throat.  Dry  ulcers  on  the  tonsils  and 
palate.  Nausea  and  vomiting  with  soreness  of  the  pit  of  the 
stomach  on  pressure  {bry.).  Suppression  of  urine  (hyos.,  (ypium); 
albuminuria  {phos.  acid).  Dyspnoea  with  great  restlessness  and 
trembling  {ars.  alb.) 

Arsenicum.— Great  sinking  of  strength  {verai.  alb.)  with 
burning  heat  and  extreme  restlessness  {camphor).  Frequent, 
small,  trembling  pulse.  Irregular  action  of  the  heart,  absence 
of  the  second  sound.  Tongue  red,  dry  and  cracked.  Dryness 
of  the  moufch  with  violent  thirst,  drinks  often,  but  little  at  a  time 
{bell,  opp.  bry.).  The  eruption  is  intermixed  with  petechise 
{rhus).  The  pustules  sink  in  and  their  areolae  grow  livid  {lack.). 
Mild  delirium  with  convulsive  twitchings  of  the  tendons.  Dysp- 
noea, constantly  changing  position.  Violent  diarrhea.  Typhoid 
symptoms. 

Baptisia.— Dull,  stupefying  headache  {gels.).  Nausea  fol- 
lowed by  vomiting.  Great  prostration  with  excessive  pain  in  the 
lower  part  of  the  back.  The  eruption  is  more  marked  in  the 
throat  than  upon  the  skin.  Foetid  breath  with  profuse  salivation 
{mere).  Dark,  red  face  with  besotted  expression.  Dyspnoea 
and  great  nervous  restlessness.  Dysenteric  stools.  Offensive 
secretions. 

Belladonna.  —High  fever  and  sore  throat.  Severe  head  symp- 
toms with  delirium.  Eyeballs  red  and  injected  with  intolerance 
of  light  Pain  in  the  back  as  if  it  would  break.  Throbbing  of 
the  carotids  {gels.).  Intense  swelling  of  the  skin  and  mucous 
membrane  (opis).  Violent  tonsilitis  with  stitching  pain.  Diffi- 
cult deglutition;  fluids  SAvallowed  return  through  the  nose  {kali 
hick,  lack. ).  Dry,  spasmodic  cough,  worse  at  night  {hyos. ).  In- 
voluntary micturition  and  defecation.  Jerking  of  the  bedclothes. 
Starts  as  if  in  affright  on  awaking  or  during  sleep  {ars.). 

Bryonia.— Great  prostration  with  coldness  or  mixed  chill  and 
heat.  Stitches,  soreness  and  dry  feeling  in  the  throat.  Extreme 
sensitiveness  of  the  epigastrium  to  the  touch  {apis).  Nausea 
and  faintness  on  rising.  Restless  sleep  with  moaning  and  with 
chewing  motions  (6eH.).  Obstinate  constipation.  Chest  symp- 
toms. 


.  ^^»,..-.A. 


LEADING  INDICATIONS. 


355 


illing  with  stinging, 
s  on  the  tonsils  and 
s  of  the  pit  of  the 
irine  (Jiyos.,  opium); 
eat  restlessness  and 

{verai.  alb.)  with 
nphor).  Frequent, 
the  heart,  absence 
cracked.  Dryness 
,  but  little  at  a  time 
xed  with  petechise 
ise  grow  livid  (lack.). 
the  tendons.  Dysp- 
diarrhea.    Typhoid 

gels.).  Nausea  fol- 
■xcessive  pain  in  the 
lore  marked  in  the 
th  profuse  salivation 
aression.  Dyspnoea 
ic  stools.    Offensive 

Severe  head  symp- 
ted  with  intolerance 
reak.  Throbbing  of 
lie  skin  and  mucous 
itching  pain.  Diffi- 
rough  the  nose  {kali 
it  night  (/it/os.).  In- 
ig  of  the  bedclothes. 
y  sleep  (ars.). 

IS  or  mixed  chill  and 
the  throat.  Extreme 
ch  (apis).  Nausea 
h  moaning  and  with 
)ation.    Chest  symp- 


Camphor.— Sudden  and  great  sinking  of  strength  wi'h  cold- 
ness of  the  surface  {nrs.).  Sudden  collapse  from  exhaustion  of 
the  vital  forces  (verat  alb.).  The  eruption  suddenly  disappears 
and  the  pustules  appear  to  dry  up  rapidly.  Dyspnoea  with  sen- 
sation of  constriction  around  the  throat  with  hot  breath.  Small, 
weak,  scarcely  perceptible  pulse  {carbo.  veg.).  Rattling  in  the 
throat;  involuntary  evacuations. 

Cantharis.— The  eruption  assumes  the  hemorrhagic  form. 
Tonsilitis  with  inability  to  swallow.  Thirst  with  aversion  to  all 
fluids  {bell).  Dysuria  and  bloody  urine.  Albuminous  urine 
with  cylindrical  casts  {terebinthina).  Hemorrhages  from  the 
nose,  mouth,  intestinal  canal,  urinary  and  genital  organs. 

Carbo.  Teg.— Coldness  of  the  breath  and  tongue  {verat.  alb.). 
Excessive  prostration  {ars.).  Internal  burning,  wants  to  be 
fanned  {ars.).  Livid,  purple  appearance  of  eruption  {lack.). 
Rattling  in  the  throat  with  complete  loss  of  vital  power.  Thread- 
like, scarcely  perceptible  pulse.    Ecchymoses. 

Cimicifiiga.— Dull,  heavy,  aching  pain  in  the  small  of  the 
back,  relieved  by  rest,  increased  by  motion  {bry.).  Great  mus- 
cular soreness  {am.,  bry.).  Pricking,  itching  heat  of  the  skin. 
Severe  pain  in  tKe  head  and  eyeballs,  aggravated  by  motion 
{bry.).  Redness  of  the  fauces  and  palate.  Obstinate  sleepless- 
ness {coff.,  opium).  Delirium  resembling  delirium  tremens 
{digit). 

Gelseminm. — Great  exhaustion  and  drowsiness.  Feeling  as 
of  a  band  around  the  head  above  the  ears  {mere).  Itching  of 
the  head,  face  and  neck.  Nausea  and  vomiting  with  weak, 
scarcely  perceptible  pulse.  Trembling  and  complete  loss  of 
muscular  power.     Predominance  of  nervous  symptoms. 

Hamamelis. — Tearing  pains  in  the  small  of  the  back.  Con- 
stipation with  severe  frontal  headache.  Hemorrhages  from  all 
parts. 

Hepar  sulph. — High  fever  with  redness  of  the  face  and 
hoarseness.  Stitching  pains  extending  from  ear  to  ear  when 
swallowing.  Hoarse,  croupy  cough.  Swelling  and  suppuration 
of  the  glands.  Unhealthy  skin,  slight  injuries  induce  suppura- 
tion and  ulceration. 


356 


LECTUIIES  ON   FEVEUS. 


Hydrastis. — Dull,  heavy,  dragging  pain  and  stiffness  in  the 
laml)ai'  region.  Faintness  and  prostration.  Great  swelling,  red- 
ness and  itching  of  the  skin.  Excessive  soreness  of  the  throat, 
which  is  studded  with  dark  pustules.  Obstinate  constipation. 
Is  said  to  prevent  pitting  when  used  both  internally  and  exter- 
nally. 

Hyoscyamus.— Late  appearance  of  the  eruption,  causing  great 
ner^'ous  excitement.  Constant  desire  to  get  out  of  bed.  Red, 
sparkling,  staring  eyes  {bell).  Constrictive  sensations  in  the 
throat  with  inability  to  swallow  (bell.).  Involuntary  stools  at 
night  {ars.,  rhns).  Retention  of  urine  (opium).  Grating  of 
the  teeth  {a2ns,  hell. ).  HypersBsthesia  of  the  skin.  Brown  spots 
or  gangrenous  vesicles  on  the  body. 

Lachesis. — Headache  mostly  in  the  forehead  with  nausea  and 
chilliness.  Aggravation  of  all  the  symptoms  after  sleep.  Stu- 
por and  muttering  delirium  (upia).  Dry,  red  or  black,  cracked 
and  bleeding  tongue  {(irs.).  Oppression  of  the  chest.  Solids 
swallow  better  than  liquids.  Irregularity  of  heart  beat  (digit). 
Stitches  in  the  throat  when  swallowing.  Suppuration  of  the 
glands  of  the  neck.  Destructive  decomposition  of  both  fluids 
and  solids.  Passive  hemorrhages  of  dark  fluid  blood.  Specially 
adapted  to  a  typhoid  condition  during  suppurative  stage.  In 
intemperate  persons. 

Halandriniiiii. — Useful  as  a  preveintive,  and  when  the  secre- 
tions are  very  oflfensive.  It  almost  invariably  lessens  the  sec- 
ondary fever.  (Malaudrinum  is  attenuated  lymph  from  the 
horse-pox  vesicle. ) 

Mercurius. — Great  restlessness,  weariness  and  prostration. 
Swollen,  soft,  flabby  tongue,  taking  the  imprints  of  the  teeth. 
Putrid  odor  from  the  mouth  (bapt).  Ulcerated  throat  with 
profuse  salivation.  Diarrhea  or  dysentery  with  tenesmus.  Per- 
spiration without  relief  (ars.,  opp.  flfefe.).  Adapted  to  the  sup- 
purative stage. 

Opium. — Complete  loss  of  consciousneis  with  slow  stertorous 
breathing.  Face,  dark  red,  hot  and  bloa'^ed  (6eZi.).  Bed  feels 
hot,  can  hardly  lie  on  it.  Difficult,  intermitting  breathing  as 
from  paralysis  of  the  lungs  (lye,  tart.  emet).  Retention  of 
urine.    Picking  at  the  bedclothes.     In  children  and  old  people. 

Phosphorus. — Stupefying  headache  with  acuteness  of  smell 


..  .-^..^^-^^^^. 


LEADING  INDICATIONS. 


867 


n  and  stiffnoas  in  the 
.  Great  Hwellinj,',  red- 
soreness  of  the  throat, 
►bstinate  con8tii)ati<)ii. 
h  interuully  and  exter- 

eruption,  causing  great 
get  out  of  bed.  Red, 
ctive  sensations  in  the 
Involuntary  stools  at 
{opinm).  Grating  o£ 
the  skin.    Brown  spots 

rehead  Avith  nausea  and 
toms  after  sleep.  Stu- 
y,  red  or  black,  cracked 
m  of  the  chest.  StJids 
ty  of  heart  beat  {digit. ). 
g.  Suppuration  of  the 
upositiou  of  both  fluids 
k  fluid  blood.  Specially 
suppurative  stage.    In 

vre,  and  when  the  secro- 
ariably  lessens  the  sec- 
auated  lymph  from   the 

ariness  and  prostration. 
16  imprints  of  the  teeth. 
.  Ulcerated  throat  with 
«ry  with  tenesmus.  Per- 
}.).    Adapted  to  the  sup- 

meis  with  slow  stertorous 
Ao&'^Gd  {hell).  Bed  feels 
atermitting  breathing  as 
,rt.  emet).  Retention  of 
children  and  old  people. 
)  with  acuteness  of  smell 


{hrll).  Difficulty  of  hearing,  especially  of  the  human  voice. 
Soreness  of  the  stomach  and  abdomen  to  the  touoli.  Pain  in  the 
back,  as  if  broken  {rhus).  Extensive  petecliiio  or  liemorrhages. 
BlotMly  pustules,  Pneumtmic  complications  { hjc. ).  Small,  quick, 
easily  compressed  pulse.  Dry,  immovable  tongue,  cracked  and 
covered  with  sordes  {ars.,  vci-ut  alb. ).  After  over-doses  of  cam- 
})]ior. 

Phosphoric  acid.— Great  fear  of  death.  Headache,  worse 
from  the  least  shaking  or  noise  {bidl).  Dryness  of  the  mouth 
and  throat  without  tliirst  (mix).  Involuntary  stools;  watery 
diarrhea.  The  pustules  don't  fill  with  pus,  but  degenerate  into 
large  blisters  which  burst  and  leave  the  surface  excoriated.  Con- 
fluent small-pox. 

Rlllis  tox. — Great  restlessness  and  uneasiness  {ars. ).  Bruised 
pains  in  the  small  of  the  back  wlien  sitting  still  or  when  lying; 
better  from  motion.  Active  delirium  and  gi-eat  prostration. 
Vivid,  troublesome  dreams  of  excessive  bodily  exertion.  Dark, 
livid  redness  of  the  cheeks.  Redness  of  the  tip  of  the  tongue 
in  the  shape  of  a  triangle.  Sordes  on  the  lips  and  teeth.  Hem- 
orrhage from  the  mucous  surfaces  and  into  the  pustules.  The 
eruption  shrinks  and  looks  livid.  Erysipelas  with  great  burning. 
Glandular  swellings.  Confluent  small-pox  with  typhoid  symp- 
toms. 

Sarracenia. — Is  said  to  have  curative  or  prophylactic  virtues 
in  this  disease. 

Sulphur.— During  the  stage  of  desiccation,  and  when  the  dis- 
ease pursues  an  irregular  course. 

Tartar  emet.— Stupefying  headache  with  pressure  from  with- 
out inwards,  in  the  forehead  and  root  of  the  nose.  White,  pasty 
coating  on  the  tongue.  Tongue  red  in  streaks  and  dry  in  the 
middle  (rhus).  Continuous,  anxious  nausea  (ipecac).  Watery, 
slimy,  bloody  diarrhea.  Great  rattling  of  mucus  in  the  chest 
Excessive  restlessness.  The  pustules,  after  drying,  leave  bluish- 
red  marks.     Typhoid  pneumonia. 

Thiya.— Boring,  stitching  pains  in  the  forehead,  temples  and 
over  the  eyes.  Conjunctivae  inflamed  and  red  like  blood.  (Edem- 
atous swelling  of  the  face  (apis).  Marked,  dark  red  areola 
around  the  pustules.  Rawness  and  dryness  in  the  throat.  Burn- 
ing from  the  small  of  the  back  to  between  the  shoulders  (phos.). 


i 


,• 


Sa«:*ri,/i<iAn,5»B*i«sie»iaiiiR.i&'>.)*H«saaf..^^ 


MjKSnSwMiMte"*^ 


358 


LECTURES  ON   FEVERS. 


Painful  drawing  in  tlio  sacrum,  coccyx  and  thiglis,  wliilo  sitting. 
Specially  adapted  to  the  stage  of  suppuration. 

Vaccillili mil. —Great  fear  of  taking  small-iHix,  is  said  to  be  n 
characteriHtic.  Has  been  used  with  success  in  all  stages.  (Vuc- 
cininum  is  attenuated  lymph  from  the  cow-pox  vesicle, ) 

Yariolinilili. — Especially  when  throat  symptoms  are  promi- 
nent. Is  said  to  cause  the  disease  to  run  a  mild  course,  and 
prevent  scarring.  (Variolinum  is  attenuated  lymph  from  the 
small-pox  vesicle. ) 

Veratnim  vir.— Severe  frontal  headache  with '  Limiting.  Sud- 
den spasms  with  nausea,  vomiting  and  utter  prostration.  Red 
streaks  in  the  middle  of  the  tongue;  yellow  edges.  Burning  in 
the  fauces  with  constant  inclination  to  swallow.  Intense  fever 
with  irregular,  hard,  frequent  pulse.  Oppression  of  the  chest 
with  slow,  labored  breathing.  Profuse  sweat.  Itching  and  burn- 
ing of  the  skin.     In  plethoric  individuals. 

HYQIENIO  AND    DIETETIC   TREATMENT. 

The  general  management  and  nursing  of  the  small-pox  patient 
are  highly  important.  The  sick  room  should  be  large,  icell-ren- 
tilated,  and  moderately  darkened.  The  temperature  of  the 
apartment  dhould  be  kept  below  60°  Fahr.,  which  in  winter 
should  be  heated  by  an  open  fireplace  rather  than  by  hot  air. 
Carpets  and  ail  unnecessary  articles  of  furniture  should  be  re- 
moved. The  strictest  attention  should  be  given  to  cleanliness 
and  to  the  use  of  disinfectants.  Piatt's  chlorides,  a  solution  of 
carbolic  acid  or  of  potassium  permanganate,  should  be  sprinkled 
freely  over  the  bed  and  on  the  floor.  Cloths  wet  in  the  solution 
should  also  be  suspended  in  the  room.  The  physician  or  nurse 
should  wash  the  hands  in  some  disinfecting  fluid,  on  every  oc- 
casion for  touching  the  patient 

The  body  may  be  sponged  with  or  bathed  in  tepid,  carbolized 
water  as  often  as  proves  grateful.  In  severe  or  confluent  cases, 
the  continuous  warm  bath  as  practiced  in  Vienna  renders  excel- 
lent service.  When  the  pustules  rupture,  carbolized  baths  are 
frequently  effectual  in  relieving  the  itching.  During  desquama- 
tion, warm  baths  every  two  or  three  days  followed  by  oiling  the 
body,  are  useful  in  removing  the  crusts.  When  the  pain  from 
the  distension  of  the  vesicles  is  intense,  the  parts  may  be  soaked 
in  hot  water.or  hot  water  compresses  applied  for  fifteen  or  twenty 


tmmmm 


IlVdIKNIC   AND   DIETETIC  TUEATMKNT. 


\m 


I,  wliiJp  sitting. 

in  Bniil  to  be  a 
Htages.    ( Viic- 
'Hicla ) 

Ills  are  promi- 

(1  course,  Hiid 

inpli  from  the 

niting.   Sml- 

istrntioii.     Eed 

•    Burning  in 

Intense  fever 

•n  of  the  chest 

hing  and  burii> 


all-pox  patient 
arge,  icelUven' 
brature  of  the 
liich  in  winter 
an  by  hot  air, 
i  should  be  re- 
to  cleanlinosB 
8,  a  solution  of 
Id  be  sprinkled 
in  the  solution 
sioian  or  nurse 
i,  on  every  oc- 

pid,  carbolized 
)nfluent  cases, 
renders  excel- 
zed  baths  are 
ng  desquama- 
by  oiling  the 
the  pain  from 
nay  be  soaked 
«en  or  twenty 


minutoH,  and  tlie  vcsieleH  punctured  to  allow  llic  escape  of  their 
conteiitH.  To  ciiirect  the  oft'ensive  oilor  during  the  Huppurative 
htagp,  tliP  Hurfiice  may  Ini  fip([uently  bathed  and  the  tiiroat  gar- 
gled with  a  weak  Holutjon  of  p«)taHHimn  pennanpuiato  (five  or 
t«'n  grains  to  a  quart  of  water),  or  Piatt'H  chlorides  (one  part  to 
ten  or  tifteen  of  water).  In  confluent  cascH  wiiere  the  blebs 
break,  marked  benefit  is  derived  from  dusting  the  raw  surffice 
with  a  powder  of  starch  and  zinc  oxide. 

When  the  mucous  membrane  of  the  throat  is  highly  inflamed, 
considerable  relief  is  experienced  from  holding  small  pit^ces  of 
cracked  ice  in  the  mouth.  A  siKinge  wrung  out  in  hot  water, 
repeated  as  it  cools,  often  relieves  the  intense  pains  in  the  back. 
Hot  cloths,  as  hot  as  can  be  borne,  nmy  be  applied  to  the  head 
when  headache  is  severe.  Hot  water  compresses  may  also  be 
resorted  to  when  there  is  considerable  oedema  of  the  face  and 
eyelids.  The  general  smarting  pain,  frequently  experienced 
over  the  wlu>le  of  the  cutane(m8  surface,  may  often  be  relieved 
by  inunctions  with  mildly  carbolized  vaseline.  The  position  of 
the  patient  in  bed  should  be  frequently  changed  so  as  to  avoid 
constant  pressure  on  the  back  or  nates. 

The  ircaimcnt  of  flw  eruption  with  a  view  to  preventing  scar- 
ring and  disfiguration,  is  of  the  greatest  importance.  Usually 
the  best  results  are  obtained  from  careful  evacuaiion  of  the  ves- 
icU's  by  means  of  a  fine  needle,  and  the  constant  use  of  carbolized 
water  dressings.  And  yet  you  will  do  well  to  remember  that  no 
measures  will  prevent  the  occurrence  of  a  distinct  cicatrix  when- 
ever the  integrity  of  the  papillary  layer  of  the  corium  is  de- 
stroyed. If  the  pustules  remain  superficial  th«  pitting  will  be 
slight,  but  if  the  true  skin  becomes  involved,  i)itting  will  occur 
in  spite  of  treatment. 

The  diet  consists  principally  of  rice,  corn  starch  and  milk^ 
whicli  may  be  taken  ice  cold  if  desired.  After  three  or  four 
days  beef  tea,  chicken  broth,  mutton  broth,  or  yolks  of  eggs 
beaten  up  in  milk,  may  be  alternated  with  milk.  Water  may  be 
administered  freely,  and  if  preferred  may  be  given  cold. 

Stimulants  should  be  given  in  cases  of  great  prostration,  and 
when  extensive  suppuration  threatens.  They  may  be  given  alone 
or  in  the  form  of  wine  whey  (p.  194),  or  brandy  punch  (p.  306). 

If  constipation  is  'present  it  may  be  relieved  by  the  adminis- 
tration of  enemas. 


nmttM'mmimmmmim 


Mmfta 


,  LECTURE  XXIII. 

Varioloid  and  Vaccination. 

To-dny,  l)efore  dirocting  yf)ur  attention  to  varioloid  or  modijlrd 
snuill-pox,  I  will  give  (i  passiuy  notice  to  cow-pox,  vaccinia  in 
the  human  nubject,  inoculation  and  vaccination. 

Cow-Pox. 

Definition.— Cow-pox  is  a  specific  eruptive  disease,  occurring 
chiefly  on  the  teats  and  udders  of  milch  cows,  and  is  character- 
ized by  the  development  of  piipular,  vesicular  and  pustular  le- 
sions. It  may  appear  either  sporadically  or  as  an  epizootic,  and 
is  mainly  communicable  by  actual  contact. 

Synonyms. — Kine-pock.    Vaccine  disease. 

History. — Cow-pox  has  prevailed  from  time  immemorial,  but 
is  not  as  prevalent  now  as  formerly.  It  may  prevail  at  all  sea- 
eons  of  the  year  except  midsummer,  but  is  most  common  during 
the  months  of  May  and  June. 

Etiology.— It  may  be  induced  in  cows  in  either  of  three  ways: 
1.  By  inoculation  with  the  virus  from  affected  cows.  2.  By  in- 
oculation with  the  virus  of  horse-pox.  3.  By  inoculation  with 
the  virus  of  small-pox. 

Clinicai  History.— After  an  incubation  of  from  three  to  four 
days  the  parts  become  hot  and  tender,  and  a  few  small,  red  pa- 
pules appear  on  the  base  of  the  teats  and  udder,  which  in  three 
or  four  days  change  into  vesicles  and  become  umbilicated.  The 
vesicles  are  usually  pea-sized,  present  a  glistening  appearance, 
and  are  generally  oval  on  the  body  of  the  teats  and  udder,  but 

(3C0) 


I 


VACCINIA. 


;wii 


>i(l  or  modified 
)X,  vaccinia   iu 


ease,  occurring 
1(1  iH  chnracter- 
J  pustular  le- 
1  epizootic,  and 


nmemorial,  but 
)vnil  at  all  sea- 
jommon  during 

of  three  ways: 
►ws.  2.  By  in- 
oculation with 

m  three  to  four 
'  small,  red  pa- 
which  in  three 
Dilicated.  The 
ig  appearance, 
ind  udder,  but 


circnlnr  on  tho  hnso  and  neck  of  tlio  tontH.  On  the  piRlith  or 
ninth  (lay  a  pale,  roHt^-coIorcd  iiniola  iippoiirH  nround  tlii>  vcsicln, 
wliirli  Httmdily  cnlarjiicH  until  tli»>  tciitli  «»r  twolfth  day,  wlicii  it 
liiiH  attained  tli*^  width  of  ii(>ni'ly  half  iiii  iiioh.  TIh^  lymph  in  tho 
V(>si('l('i  heconK'H  opacpie  aboiit  tho  tw«'lfth  day,  and  dcHiccation 
takoH  place  leaving  browniHii-black  cruHtH  which  full  i>tV  in  about 
throo  weeks. 

Horso-pox. — Horso-pox  is  a  Himilar  disoaso  to  cow-pox,  ond 
will  i)rotluce  vaccine  disoasti  in  the  cow.  Its  eruption  is  more 
ptMK^'alized  than  that  of  cow-pox,  and  appears  on  the  trunk  and 
limbs  as  well  as  upon  the  nasal  and  buccal  mucims  inendmines. 

Yaccliiiii (IN  MAN.) 

Definition. — Vaccinia  is  an  affection  produced  by  the  intro- 
duction into  tho  human  system  of  the  virus  of  cow-pox,  or  of 
humanized  virus — a  few  removes  from  the  cow-pox.  It  is  conta- 
gious only  by  inoculation,  and  possesses  valuable  protective 
properties  against  small-pox. 

Synonym.— Vaccine  disease. 

Clinicai  History.— Between  the  third  and  fourth  doys  after 
the  intnwluction  of  the  virus  into  the  tissues  of  a  previously  un- 
Vttccinated  subject,  a  light  reddish,  pin-heod  sized  papule  arises 
at  the  point  of  operation.  On  the  iifth  day  an  oval  or  circular 
vesicle  of  a  bluish-white  color,  and  surrounded  by  a  yellowish- 
white  margin  makes  its  appearance.  This  vesicle  increases  in 
size  and  becomes  umbilicated  <m  the  sixth  day.  It  is  now  sur- 
rounded by  a  very  narrow  ring  of  inflammation — the  areola.  On 
the  eighth  day  the  vesicle  reaches  its  highest  degree  of  develop- 
ment and  is  about  one-third  of  an  inch  in  diameter.  It  is  filled 
with  a  thin,  transparent  fluid,  which  becomes  opalescent  on  the 
ninth  day.  The  contents  of  the  typical  vesicle  are  auto-inocu- 
lable.  ( Between  the  fifth  and  eighth  days  is  the  time  to  take 
lymph  for  the  purpose  of  vaccination).  The  areola  enlarges 
during  the  ninth  and  tenth  days,  and  attains  its  maximum  size 
of  about  two  inches  in  diameter.  It  is  of  a  brilliant  scarlet  or 
dark  red  color,  and  is  most  intense  at  the  edge  of  the  vesicle. 
The  skin  and  cellular  tissue  become  hardened  and  tumefied; 
heat,  itching  and  tenderness  are  usually  marked.  The  contigu- 
ous lymphatic  glands  are  apt  to  be  irritated  and  swollen. 


ftmti^tttutm^mvttUk 


3.5ro6«ny»*9i«tf»jcs.<  -- 


362 


LECTURES  ON   FEVERS. 


After  the  tenth  cc  eleventh  day  the  disease  begins  to  subside. 
Tlie  red  areohi  fades,  the  swelling  and  induration  of  the  tissues 
abate,  and  the  pustule — for  such  it  has  become — either  ruptures 
or  begins  to  dry  up.  Desiccation  of  the  pustule  progresses  rap- 
idly, so  that  nhont  the  fourteenth  or  fifteenth  day  a  firm,  hard, 
dark-brown  or  mahogany-colored  scab  has  formed,  having  a  cen- 
tral depression  and  no  areola  of  inflammation.  The  scab  grad- 
ually separates  from  the  tissues  and  falls  off  about  the  eighteenth 
or  twenty-first  day,  leaving  a  circular  or  oval  depression  or  cica- 
trix, studded  with  several  minute  pits  or  dots.  The  cicatrix  is 
at  first  of  a  deep  red  or  purple  color,  but  fades  gradually  until  it 
finally  assumes  a  dead-white  color.  The  shape  and  size  of  the 
scar,  crust  and  \esicle  correspond  with  the  scarification,  and  will 
be  circular  or  irregular,  according  as  the  latter  is  circular  or 
irregular.  Although  usually  indelible,  many  of  the  most  per- 
fect cicatrices  disappear  entirely  as  life  advances. 

The  constitutional  disturbances  are  usually  very  slight.  The 
febrile  reaction  about  the  eighth  day  differs  in  different  subjects, 
&nd  is  generally  more  severe  when  bovine  virus,  procured  re- 
cently from  the  cow,  is  used,  than  when  humanized  virus  is  in- 
troduced. 

Individuals  possess  different  degrees  of  susceptibility  to  vac- 
cinia at  different  times.  Children  are  usually  more  susceptible 
than  adults. 

Irregularities. — The  deviations  from  the  regular  course  of 
development  of  vaccinia  may  be  either  normal  or  abnormal. 

1.  The  Normal  IiTegularities. — Betardatioii  in  the  appearance 
of  the  vesicle  is  not  uncommon.  The  vesicle  may  not  show 
itself  until  the  sixth  or  eighth  day,  and  yet  the  disease  may 
afterwards  run  a  normal  course,  with  no  diminution  of  protective 
power. 

When  vaccination  is  performed  during  the  incubation  periods 
of  either  measles,  scarlet  fever  or  chicken-pox,  and  the  vesicles 
do  not  reach  the  stage  of  areola,  before  the  symptoms  of  the 
particular  disease  become  manifest,  the  areola  will  not  form 
until  the  disease  has  run  its  course. 

Old  vaccinations,  apparently  unsuccessful,  have  not  infre- 
quently been  revived  by  recent  vaccination. 

2.  The  Abnormal  Irregulariiies. — Vaccinia  is  spurious  when 
it  assumes  any  of  the  following  aspects: 


^■OW'c  •" 


COMPLICATIONS. 


363 


sase  begins  to  subside, 
uration  of  the  tissues 
3ome — either  ruptures 
ustule  progressys  rap- 
enth  day  a  firm,  hard, 
formed,  having  a  cen- 
ition.  The  scab  grad- 
I  about  the  eighteenth 
val  depression  or  cica- 
dots.  The  cicatrix  is 
"ades  gradually  until  it 
shape  and  size  of  the 
i  scarification,  and  will 
he  latter  is  circular  or 
many  of  the  most  per- 
dvances. 

aally  very  slight.  The 
rs  in  different  subjects, 
ae  virus,  procured  re- 
humanized  virus  is  in- 

»f  susceptibility  to  vac- 
Bually  more  susceptible 

I  the  regular  course  of 
ormal  or  abnormal. 
lation  in  the  appearance 
vesicle  may  not  sLow 
i  yet  the  disease  may 
liminution  of  protective 

J  the  incubation  periods 
en-pox,  and  the  vesicles 
e  the  symptoms  of  the 
le  areola  will  not  form 

sssful,  have  not  infre- 

on. 

ccinia  is  spurious  when 


a. — The  appearance  of  rod,  pea-sized  tubercles  at  the  seat 
of  vaccination. 

b,-~Tlie  development  of  acuminated  instead  of  umbilicated 
vesicles,  with  marked  itching.  Instead  of  containing  clear  lymph, 
the  vesicles  contain  a  straw-colored  fluid.  The  scabs  fall  off  as 
early  as  the  tenth  day. 

c, — The  formation  of  a  bulla  or  bleb,  instead  of  a  papule  or  ves- 
icle. 

^, — The  appearance  of  herpetic  vesicles  in  crops,  about  the 
third  day,  preceded  by  shivering  and  accompanied  by  intolerable 
itching. 

<•.— The  sudden  rupture  and  formation  of  ulcers,  in  vesicles, 
which,  up  to  the  eighth  or  ninth  day,  have  apparently  run  a  nor- 
mal course. 

Complications. — Vaccinal  eruptions  are  not  uncommon  after 
the  ninth  day  of  vaccine  disease.  Roseola,  cry  Ihema  muUiforme 
and  lichen  are  oftenest  met  with,  and  are  geneinlly  of  a  benign 
charncter. 

Erysipelas  is  comparatively  rare,  but  if  it  does  occur  during 
the  course  of  development  of  the  vaccine  vesicle,  it  completely 
destroys  the  protecting  power  of  the  vaccination.  The  cause  of 
the  development  of  erysipelas  during  vaccinia  i<j  frequently 
found  in  the  constitution  and  habits  of  the  vaccinated  individual. 

Eczema. — In  eczematous  subjects,  eczema  is  often  aroused, 
and  is  apt  to  interfere  with  the  development  of  the  vesicle,  and 
may  render  the  vaccination  non-protective.  It  is  advisable, 
therefore,  not  to  vaccinate  an  individual  suffering  from  any  form 
of  skin  disease,  particularly  if  it  is  vesicular  in  character. 

Syphilis  ffay  be  transmitted  by  vaccination  with  impure  hu- 
manized viius,  or  by  using  an  infected  instrument.  In  such 
cases  the  blood  of  the  syphilitic  individual  must  have  beconae 
mixe'^i  with  the  lymph,  or  else  a  vaccine  crust  from  a  syphilitic 
person  must  have  been  used.  For  pure,  unmixed  vaccine  lymph 
cannot  communicate  syphilis  even  though  taken  from  a  syphi- 
litic patient  Inherited  syphilis  not  infrequently  develops  axter 
vaccination,  even  when  animal  virus  is  used. 

Olandular  Swellings.— In&ammaiion  and  suppuration  of  con- 
tiguous lymphatic  glands  sometimes  occur,  and  are  annoying, 
though  by  no  means  dangerous  complications. 


'»»»!•».««<■»«"'■■"■  ■■••"■^"^""'•*"''' 


-•.-:m«n?«-^MtMMMI 


304 


LECTURES  ON  FEVERS. 


i. 


Inoculation. 

Deflllition. — Inoculation  is  the  now  obsolete  method  of  ren- 
dering small-pox  poison  innoxious,  by  introducing  variolous 
lymph,  taken  on  the  fifth  or  sixth  day  of  the  eruption,  into  the 
arm,  and  producing  a  contagious  disease — capable  of  transmit- 
ting small-pox  to  others — which  passes  through  the  regular  stages 
of  small-pox  in  a  mild  and  rapid  course. 

History. — Inoculation  was  employed  in  China  and  India  as 
early  as  tiie  eleventh  century.  It  was  first  practiced  in  Constan- 
tinople in  1700.  Drs.  Simoni,  Kennedy  and  Pylarini  published 
an  account  of  it  in  the  English  journals  in  1714-15.  Lady  Mon- 
tague, whose  son  was  inoculated  at  Constantinople  in  1717,  in- 
troduced the  practice  into  England,  by  inoculating  her  daughter 
in  the  year  1721.  It  was  first  performed  in  this  country  in  1721 
by  Dr.  Boylston,  of  Boston,  at  the  suggestion  of  the  Rev.  Cotton 
Mather.  At  the  beginning  of  the  present  century  it  fell  into 
■disuse  upon  the  advent  of  vaccination. 

Clinical  History. — On  the  second  day  after  the  introduction 
of  the  lymph,  a  minute  orange-colored  spot  is  perceptible  by  the 
aid  of  a  magnifying  glass,  at  tlie  point  where  the  operation  is 
performed.  On  the  third  or  fourth  day  after  the  operation,  the 
punctured  point  becomes  hardened,  and  a  small,  umbilicated 
vesicle  seated  upon  an  inflamed  base  makes  its  appearance.  On 
the  fifth  day  the  vesicle  is  well  developed,  and  a  narrow,  rosy 
areola  is  formed.  On  the  sixth  day  the  parts  become  hardened, 
hot  and  painful.  In  the  evening  of  the  seventh  or  morning  of 
the  eighth  day  the  patient  is  seized  with  rigors,  headache  and 
vomiting.  Febrile  movement  follows,  and  a  variolous  eruption 
Kooii  makes  its  appearance  on  various  i^arts  of  the  body.  Usually 
not  more  than  twenty  or  thirty  vesicles  are  formed.  Sometimes 
not  more  than  three  or  four  papules  can  be  discovered.  Two  hun- 
dred vesicles  would  form  a  maximum  crop.  After  the  eighth  day 
the  inflammation  in  the  arm  spreads  with  great  rapidity,  and  a 
number  of  minute  confluent  vesicles  appear  upon  the  now  large 
ai^  irregular  areola.  On  the  tenth  day  the  arm  appears  red, 
tetfltee  and  shining,  and  the  pustule,  if  it  has  not  been  opened,  now 
bursts  and  dischirges  copiously.  The  disease  now  begins  to 
subsid^L  the  areola  fades,  and  desiccation  progresses  rapidly. 


MMNNWwaUMM 


I  imm  ij  fc^..t«M« 


VACCINATION. 


365 


3  method  of  ren- 
)ducing  variolous 
eruption,  into  the 
sable  of  transmit- 
the  regular  stages 


lina  and  India  as 
cticed  in  Constan- 
Vlarini  published 
1^-15.  Lady  Mon- 
inople  in  1717,  in- 
iting  her  daughter 
ds  country  in  1721 
of  the  Rev.  Cotton 
jentury  it  fell  into 

3r  the  introduction 
perceptible  by  the 
•e  the  operation  is 
the  operation,  the 
small,  umbilicated 
;s  appearance.     On 
and  a  narrow,  rosy 
become  hardened, 
iiith  or  morning  of 
ors,  headache  and 
variolous  eruption 
the  body.    Usually 
rmed.     Sometimes 
jovered.    Two  hun- 
'ter  the  eighth  day 
eat  rapidity,  and  a 
ipon  the  now  large 
arm  appears  red, 
t  been  opened,  now 
ase  now  begins  to 
gresses  rapidly. 


Surgery  of  Inoculation. — Inoculation  is  performed  by  intro- 
ducing a  minute  portion  of  variolous  lymph,  taken  from  a  fifth 
day  vesicle,  into  the  arm  at  the  insertion  of  the  deltoid,  by  means 
of  a  lancet. 


Mortality  .- 

one  per  cent 


-The  ratio  of  mortality  after  inoculation  is  about 


Vaccination. 


Definition. — Vaccination  is  the  introduction  of  hovine  or  hu- 
manized virus  into  the  skin  of  the  human  subject.  It  is  the 
method  usually  employed  to  induce  vaccinia  as  a  protective 
against  small-pox. 

History. — The  history  of  vaccination  dates  from  the  latter 
part  of  the  last  century.  It  is  intimately  connected  with  the 
life  of  Jenner,  who  was  born  in  1749  at  the  vicarage  of  Berkley, 
in  Gloucestershire,  and  died  in  1823,  full  of  years  and  honors. 

On  the  fourteenth  day  of  May,  1796,  Jenner  made  his  first 
vaccinnation.  It  was  performed  on  a  boy  named  James  Phipps, 
eight  years  of  age.  The  lymph  was  taken  from  the  hand  of 
Sarah  Milnes — a  milk-maid  who  had  been  infected  by  her  em- 
ployer's cows — and  inserted  by  two  superficial  incisions.  The 
patient  passed  through  the  disease  satisfactorily  and  was  tested 
on  the  first  day  of  July  following,  by  small-pox  inoculation, 
without  effect. 

Vaccination  was  introduced  into  this  country  by  Dr.  Water- 
house  of  Boston,  in  July,  1800,  with  virus  received  from  Jenner. 
It  was  introduced  into  France  the  same  year,  reached  India  in 
1802,  and  rapidly  came  into  general  use. 

The  principle  of  vaccination  introduced  by  Jenner  is  receiving 
new  development,  and  is  now  being  applied  by  Pasteur  to  the 
extinction  of  other  diseases. 

Prophylactic  Influence.— The  position  of  the  medical  profes- 
sion  on  the  protective  power  of  vaccination  against  small-pox  is, 
that  in  the  majority  of  cases,  those  who  have  gone  regularly 
through  vaccinia  are  saved  from  any  future  attack  of  small-pox, 
and  that  in  the  majority  of  cases — where  it  does  not  prevent — it 
so  modifi)  s  the  disease  as  to  deprive  it  of  all  danger  to  life. 

Marson's  table,  giving  the  results  of  observations  on  nearly 


'  IS!  lesettm  iiiKliniiiiiiWM 


'I 


366  LECTURES  ON  FEVERS. 

five  thousand  post-vaccinal  cases  of  small-pox  scattered  over  a 
period  of  twenty  years,  well  exemplifies  this  protective  power. 

Classification  of  patients  No.  of  deaths.    Per  cent 

affected  with  small-pox.  in  each  clas&. 

1.  Unvaccinated 35. 

2.  Stated  to  have  been  vaccinated,  but  having  no 

cicatrix 23.57 

3.  Vaccinated 

a.  Having  one  vaccine  cicatrix 7.73 

6.  Having  two  vaccine  cicatrices 4.70 

c.  Havin'^  three  vaccine  cicatrices 1.95 

<l.  Having  four  or  more  cicatrices 0.55 

e.  Having  well-marked  cicatrices 2.52 

/.  Having  badly-marked  cicatrices 8.82 

4.  Having  previously  had  small-pox 19. 

The  Virus. — In  this  country  vaccination  Avith  bovine  or  heifer- 
transmitted  cow-pox  virus,  is  the  rule.  The  current  stocks  '•• 
are  either  bovine  virus  or  humanized  virus,  one  or  a  few  removes 
from  tlie  cow^-pock.  The  fewer  removes  the  lymph  undergoes, 
the  more  marked  the  freedom  from  post-vaccinal  small-pox,  after 
its  use.  Vaccine  virus  whifh  has  gone  through  many  successive 
transmissions  loses  considerable  of  its  prophylactic  influence. 
The  more  frequent  occurrence  and  greater  fatality  of  post-vacci- 
nal small-pox  during  the  last  twenty  years,  is  doubtless  due  to 
the  use  of  long-humanized  virus.  Erysipelas  occurs  with  greater 
frequency  after  the  use  of  humanized  lymph,  than  after  care- 
fully selected  bovine  virus. 

Quill  slips  and  ivory  points  are  the  favorite  methods  of  pre% 
serving  animal  or  bovine  vaccine,  while  the  crust  is  the  usual 
method  of  preserving  hitmanized  vaccine. 

For  several  years  past  I  have  been  accustomed  to  vaccinate 
my  private  patients  with  bovine  virus,  using  the  well-prepared 
ivory  points.  The  points  are  always  convenient  and  cleanly,  and 
the  bovine  virus  has  in  every  case  given  satisfaction. 

Period  of  Performance. — As  a  general  rule,  if  the  health  of 
the  child  permits,  the  operation  should  be  performed  about  the 
age  of  three  months,  thus  anticipating  the  period  of  dentition. 

*Foraful1  account  of  th^  method  of  obtaining  and  storing  virus,  consult 
Hanling  on  "Essentials  of  Vaccination." 


^'■'**c»;-..^^:^.-^itejah(.;auaieia6^finftif^yy^*-;ijiK^ 


i;aaa«»iiai»<l«Mtoi»iiMiiliMiftW»iii»i»;iw»W«Miro#n^ 


?*" 


»cattered  over  a 
ective  poM'er. 

di'utlis.    Per  cent 
1  each  cloHb. 

..  36. 
igno 
..  23.57 

•  • 

. .  7.73       ! 

. .  4.70 

. .  1.95       . 

. .  0.55 

, .  2.52 

, .  8.82 

,.  19. 

)Ovine  or  heifer- 
urrent  stocks  '■• 
•  a  few  removes 
iph  undergoes, 
jmall-pox,  after 
Qauy  successive 
lactic  influence. 
;y  of  post-vacci- 
[oubtless  due  to 
ars  with  greater 
lan  after  care- 

aetliods  of  pre% 
ust  is  the  usual 

ed  to  vaccinate 

5  well-prepared 

nd  cleanly,  and 

ion. 

f  the  health  of 

med  about  the 

d  of  dentition. 

ing  virus,  consult 


REVACCINATIOX. 

Under  danger  of  infection,  however,  no  age  should  be  exempt 
from  vaccination. 

The  following  comparative  table  of  small-pox  death-fates 
among  vaccinated  and  unvaccinated  respectively,  for  one  year 
ending  May  29,  1881,  given  by  Dr.  Buchanan,  of  London,  shows 
the  value  of  infant  vaccination,  and  the  necessity  for  re-vaccina- 
tion. 

Death-rnte  per  million  among    Death-rate    per    million 
Ages  of  patients.  the  vucciuutcd.  among  the  unvaccinated. 

All  ages 90  3,350 

Under  twenty  years. . .  61  4,520 

Under  five  years . .    . .  40J 5,950 

Re-vaccination. — Ai.  persons  who  have  been  vaccinated  in 
infancy  should  undergo  re-vaccination  as  they  approach  adult 
life.  The  best  time  for  re-vaccination  is  from  fifteen  to  eighteen 
years  of  age.  All  doubtful  primary  vaccinations  should  be  put 
to  the  test  of  a  re-vaccination.  Under  danger  of  infection,  re- 
vaccination  should  be  performed,  even  if  only  a  sliort  time  has 
elapsed  sijice  a  previous  inoculation.  Dr.  Martin  reports  that 
he  has  succeeded  in  re-vaccinating  with  bovine  virus  in  seventy- 
three  per  cent  of  the  cases.  Severe  constitutional  symptoms 
occur  much  more  frequently  after  a  re- vaccination  than  after  a 
primary  vaccination. 

Surgery  of  Vaccination.— The  preferable  method  of  insert- 
ing  the  vims  is  by  scarification,  wlxich  consists  in  making  a 
number  of  single  or  double  scratches  or  cross  scratches.  A 
small,  wedge-shaped  lancet  is  all-sufficient  for  the  purpose,  but 
my  preference  is  to  use  for  each  case  a  separate  ivory  point 
charged  with  lymph.  Before  inserting  the  point  it  will  be  nee- 
essary  to  "revive"  the  lymph  with  a  minute  quantity  of  cold- 
water.  The  vaccination  should  not  be  performed  hurriedly;  the 
lymph  must  be  worked  into  the  wound  until  dry.  In  scarifying 
you  should  go  deep  enough  to  cause  a  slight  oozing,  but  not  a 
flow  of  blood. 

The  usual  place  for  performing  vaccination  is  upon  the  left 
arm,  at  the  insertion  of  the  deltoid  muscle,  and  along  its  poster- 
ior border.  The  several  scarifications  or  punctures — if  valvular 
punctures  are  resorted  to— should  be  made  at  some  little  distance 
from  each  other.    When  vaccinating  by  separate  punctures — per- 


;l 


Ki 


LECTUUE8  ON  FEVKltH. 

formed  by  introducing,  nt  nn  angle  of  about  45  degrees,  beneath 
the  cutin  ii  well-chnrged  needle  or  lancet  in  such  a  way  that  the 
lymph  may  gravitate  into  the  wound~you  should  make  such  jninc- 
tures  as  will  produce  at  least  four  separate  good-sized  vesicles, 
not  less  than  half  an  inch  apart.  After  a  perfect  vaccination  the 
united  firea  of  the  cicatrices  should  amount  to  one-half  a  square 
inch.  It  is  usually  considered  advisable  to  examine  the  vesicle 
on  the  eighth  or  ninth  day  of  the  disease,  and  also  the  cicatrix, 
as  soon  as  it  is  formed. 


Varioloid. 

Definition. — Varioloid  is  an  acute  contagious  disease,  due  to 
the  small-pox  contagion,  occumng  only  in  individuals  who  have 
been  successfully  vaccinated,  or  who  have  already  had  the  nat- 
ural or  inoculated  disease.  It  runs  through  the  same  stages  as 
small-pox,  but  is  of  shorter  duration,  and  may  abort  at  any  period. 

Synonym.— Modified  small-pox. 

Etiology.— The  etiology  of  varioloid  is  the  same  as  that  of 
small-pox.  The  virus  of  varioloid  is  capable  of  producing  in 
persons  unprotected,  a  severe  and  fatal  form  of  small-pox. 

Clinical  History.— The  initial  symptoms  are  of  the  same 
character,  and  are  often  as  marked,  as  in  cases  of  natural  small- 
pox. Not  infrequently  in  children  the  attack  begins  with  slight 
fever  attended  with  headache  and  languor,  v/hich  subsides  in  two 
or  three  days,  as  soon  as  the  eruption  appears.  The  eruption  is 
far  less  copious  than  in  the  regular  form  of  the  disease,  and 
passes  more  rapidly  through  its  successive  changes.  The  small 
red  spots  first  appear,  usually  on  the  forehead,  and  aie  immedi- 
ately followed  by  papules,  which  within  twelve  hours  may  be- 
come converted  into  vesicles.  The  vesicles  rapidly  increase  in 
size,  and  are  sometimes  umbilicated.  On  the  third  day  they 
become  changed  into  pustules,  without  any  tumefaction  of  the 
cutaneous  surface.  Secondary  fever  seldom  appears,  unless  the 
rash  is  extensive.  When  present,  it  is  usually  slight  and  gener- 
ally disappears  within  twenty-four  or  forty-eight  hours.  On  the 
fifth  day  the  pustules  begin  to  dry  up,  and  desiccation  may  be 
completed  by  the  seventh  day. 

The  scabs  begin  to  fall  as  early  as  the  eighth  day  of  the  erup- 


m>i^ifmfpm«s*miM0iimi^^ 


fmm»iSiMkimiimmMih  mmamv^- 


>.i  HM|l!i|l1<yiii»  I 


degrees,  beneath 
h  a  way  that  the 
.  make  siich  jnmc- 
od-sized  vesicles, 
t  vactiination  the 
)ne-half  a  square 
mine  the  vesicle 
also  the  cicatrix, 


CHART. 

CHART  XV.—rarioloid. 


369 


I  disease,  due  to 
aduals  who  have 
ady  had  the  nat- 
e  same  stages  as. 
ort  at  any  period. 


same  as  that  of 
of  producing  in 
small-pox. 

ire  of  the  same 
)f  natural  small- 
Jgins  with  slight 
L  subsides  in  two 

The  eruption  is 
;he  disease,  and 
ges.  The  small 
md  aie  immedi- 

hours  may  be- 
jidly  increase  in 

third  day  they 
nefaction  of  the 
)ears,  unless  the 
light  and  gener- 

hours.  On  the 
location  may  be 

iay  of  the  erup- 


Nature: 

Contatrious 

t^tajTos: 

Invasion. 

Eruption. 

Suppuration. 

Desiccation. 

Duration: 

"  to .}  Oays. 

n  days. 

•i  days. 

3  days. 

Eruption: 

Erythema  of- 
ten present. 

IstD.SndD. 

;iril  1). 

Pustules  limited. 
Small  areola. 

Deglns  on  Tjth 

day.  Com- 
pleted on  7th 
day. 

1 

2 

CD 

n 

13 
c 

r» 

C 

rt 
en 

Uinblllcated 

Ttirout: 

Soro  throat. 
DysphaBla. 

SllKht  eruption. 

Pharyngitis. 

c 

S 

0 
•( 

CO 

K 

CIS 

Tempornturo: 

100"  to  103" 

Slight  secondary 
fever. 

Vervous  System: 

(hill.    Head- 
ache.   Pain  in 
loins. 

7 

C 

I 

U 

r 
p 

c 

n 

a 

M 

a 

I 
a 

1 

Headache. 

Lassitude. 

Pulse: 

Increased  in 
frequency. 

Slightly  quick- 
ened. 

Cutaneous 
Surface. 

Pcrsplrntlon. 

Unbearable    itch- 
ing.    Sickly  oflor. 

Respirations, 

Slightly  accel- 
erated. 

Slightly  acceler- 
ated. 

Rowels: 

Constipated. 

Constipated. 

Urine: 

Scanty. 

Darker  than  noi^ 
nial. 

Eyes: 

Injected. 
Lachrymation 

Injected. 
Photophobia. 

Injected. 
Slight  nedema 

Stomach: 

Nausea 
Epigastric  ten- 
derness. 

No  tenderness. 

Slight  tender- 
ness. 

Return  of 
appetite. 

Prognosis: 

Ocnorally  favorable. 

Recurrence: 

Varioloid  seldom  recura, 

Incubation: 

From  one  to  three  weeks 

Influence: 

It  reproduces  the  contagion  of,  and  protet-ts  iiHuinst,  small-pux. 

370 


LECTUUEH  ON  FEVERS. 


tion,  and  desquamation  is  usually  completed  '^^""*  "^«  *?^f  jj' J 
fourteenth  day.  Reddish  spots  or  blotches  are  left,  which  grad- 
ually disappear  without  leaving  cicatrices. 

Duration.-The  duration  of  varioloid  varies  from  ten  to 

twenty  days. 

Differential  Diagnosis.-The  differential  diagnosis  of  vario- 

loid  is  the  same  as  that  of  small-pox.  ,  .  ,   .^  u„  „^„ 

Varioloid  differs  from  small-pox,  with  which  it  may  be  con. 
founded,  in  the  rapid  development  and  decline  of  the  eiuption 
in  the  small  number  of  pustules,  and  in  the  short  time  required 
for  the  formation  and  separation  of  the  crusts. 

Progno8i8.-The  prognosis  is  generally  good.    Exceptionally 
the  disease  proves  fatal  in  a  ratio  of  from  five  to  ten  per  cent. 
Treatment.-The  treatment  for  varioloid  is  essentially  the 
same  as  for  mild  small-pox  (p.  350). 


bout  the  twelfth  or 
i  left,  which  grad- 

,ries  from  ten  to 


Uagnosis  of  vnrio- 

ich  it  may  be  con- 
ae  of  the  eiaption, 
ihort  time  required 

B. 

od.  Exceptionally 
ve  to  ten  per  cent. 

I  is  esBcntially  the 


LECTURE  XXIV. 

Chicken-Pox. 

Definition. — Chicken-pox  may  be  defined  as  an  acute  epi- 
demic contagious  disease,  occurring  for  the  most  part  in  children, 
characterized  by  an  eruption  of  oval,  isolated,  hemp-seed  sized 
vesicle,  appearing  in  successive  crops,  accompanied  by  a  very 
moderate  constitutional  disturbance.  It  occurs  only  once  in  the 
same  individual.     The  period  of  incubation  is  eight  days. 

Synonyms. — Yaricella.  Swine-pox.  Bastard-pox.  Water- 
pox.     False  variola. 

History. — Chicken-pox  was  first  described  in  France  by  Re- 
vi^re  in  1660,  and  in  England  by  Harvey  in  1696. 

The  name  varicella,  meaning  Utile  small-pox,  came  into  use 
about  1770. 

Etiology. — The  exact  nature  of  the  specific  poison  of  chicken- 
pox  is  unknown.  It  may  be  communicated  by  inoculation,  and 
attacks  indiflferently  the  vaccinated  and  the  unvaccinated.  It  is 
commonly  a  disease  of  early  life,  and  becomes  markedly  infre- 
quent after  the  seventh  year. 

Clinical  History. — After  an  incubation  of  from  four  to  sev- 
enteen— usually  eight — days,  the  attack  sets  in  with  slight  chilli- 
ness, headache,  languor,  and  occasionally  vomiting,  followed  by 
more  or  less  marked  febrile  movement.  In  twenty-four  hours 
the  eruption  appears  in  the  form  of  small,  deep-red  papular 
spots — varying  in  number  from  one  dozen  to  several  hundred — 
first  upon  the  back  and  chest,  and  then  upon  the  face  and  ex- 
tremities. On  the  second  day  the  papules  have  become  converted 
into  vesicles.    The  vesicles  are  of  small  size,  usually  less  than 

(371) 


372 


LKCTUREH   ON   FEVEB8. 


one-fifth  of  nil  inch  in  (linmeter,  oblong  in  shnpp,  nnd  contain  ji 
clenr,  trivnapiiivnt  lliiid  which  gives  them  a  hriglit  iind  glistening 
appearanc'o.  After  twenty-four  hcmrH  they  become  slightly  tur- 
bid and  lact(wcont— not  puriforni.  On  the  fourth  day  desicca- 
tion begins,  and  is  usually  completed  within  two  dayn.  Tiio 
scabs,  which  are  thin,  superficial,  and  of  a  light-brown  coU)r,  fall 
off  between  the  eighth  and  ninth  days.  A  peculiar  feature  oi 
chicken-pox  is  the  appearance  of  the  vesicles  in  successive  crt)ps. 
Not  infrequently  fifty  or  one  hundred  new  spots  will  be  observed 
to  appear  each  night  for  four  or  five  days.  The  eruption  is  gen- 
erally attended  with  considerable  itching,  and  some  slight  con- 
stitutional disturbance.  The  temperature  rarely  exceeds  100° 
Falir. 

Duration.— The  duration  of  chicken-pox  varies  from  four  to 
seven  days. 

Differential  Diagnosis. — The  disease  with  which  chicken-pox 
is  of tenest  confounded,  is  varioloid.  The  following  are  the  chief 
diagnostic  points: 

The  stage  of  invasion  in  varioloid  is  longer  and  the  initiatory 
fever  is  much  more  severe  than  in  chicken-pox.  The  chicken- 
pox  rash  appears  on  the  second  day,  and  in  a  few  hours  becomes 
vesicular,  while  the  vnriolcid  rash  both  appears  and  undergoes 
vesiculation  later.  In  varioloid,  as  in  ordinary  small-pox,  the 
eruption  appears  first  on  the  face;  in  chicken-pox  it  appears  first 
on  the  body.  The  eruption  comes  out  regularly  in  varioloid,  and 
some  of  the  vesicles  are  umbilicated.  In  chicken-pox  it  comes 
out  irregularly  and  in  successive  crops,  and  presents  n.)  umbili- 
cation.  The  mildness  of  the  constitutional  symptoms  is  always 
marked  in  chicken-pox. 

Prognosis. — The  prognosis  is  always  favorable,  unless  com- 
plications arise.  Kecurrences  of  the  disease  have  never  been 
observed. 

Treatment.— Chicken-pox  requires  little  treatment  beyond 
attention  to  diet,  and  the  careful  avoidance  of  pr  ^mature  expo- 
sure to  atmospheric  changes.  Rhus  iox.  is  usually  the  only 
internal  remedy  required.  If  there  is  much  febrile  disturbance 
aconite  may  be  of  service.  Apis  met  will  prove  useful  if  there 
is  much  itching  with  the  eruption.  Belladonna  may  be  needed 
as  an  intercurrent  remedy  for  headache  and  sore  throat.    Mer- 


mm 


t 

A 


11(1  contain  n 
id  glistening 
slightly  tar- 
dily dcHicca- 
I  dayr4.  Tho 
\n  coU)r,  full 
ar  featuro  ot 
iebsive  crops, 
be  observed 
ption  is  gen- 
ie slight  con- 
axceeds  100° 

from  four  to 

1  chicken-pox 
are  the  chief 

the  initiatory 
The  chicken- 
ours  bect)mes 
nd  undergoes 
iuall-T)ox,  the 
b  appears  first 
irarioloid,  and 
-pox  it  comes 
its  n.)  umbili- 
ams  is  always 

,  unless  com- 
e  never  been 

;ment  beyond 
smature  expo- 
ally  the  only 
e  disturbance 
Lseful  if  there 
my  be  needed 
throat.    Mer- 


U.CTUUKH  ON   FEVKIIS. 

curius  or  fnrtar  emet.  will  be  culled  for,  if  any  ot  tho  veBicles 
throiiUni  to  Hap|mrivte. 

Tho  (liot  Hliould  bo  light  and  Tion-stimulatiuK — milk  in  iiHiinlly 
prcifcrrtid.  The  irritfitidii  (if  tiio  Hkin  is  b'Jbt  relieved  by  the 
applicutiuu  of  oil  or  cuHuiuliiie. 

Miliary  Fever. 

Though  not,  titrictly  speaking;,  a  contagious  diBPnne,  miliary 
fever  in  includoM  jn  this  clans,  by  reawon  of  its  poa? '  ;<Bing  many 
elements  of  contagion,  nuA  it  is  described  here  on  account  of  its 
phenomenal  prevalence  in  ;\)unection  with  meanles  and  scarlet 
fever. 

Deflnitioii. — Miliary  fever  may  be  defined  as  an  acute  fol  vile 
affection,  occurring  in  the  form  of  sliort,  circumscribed,  \r,.,^al 
epidemics,  characterized  by  profuse  sweating  attended  with  iiigh 
fever,  intense  pain  at  the  epigastrium,  and  a  sense  of  sutfocation, 
followed  after  the  third  c-r  fourth  day  Ly  u  vesicular  eruption, 
which  in  two  or  three  day:;,  disappears  by  desquamation.  Its 
average  duration  is  from  five  to  eight  days.  Belapses  are  com- 
mon. 


Synonyms. — Sweating  sickness. 
anglicuB. 


Sudoral  exanthema.    Sudor 


History. — The  history  of  miliary  f over  dates  back  to  the  close 
of  the  fifteenth  century,  Avhen  it  was  first  clearly  described  un- 
der the  name  of  the  "English  sweating  sickness." 

It  appeared  in  England  in  1486,  shortly  after  the  battle  of 
Bosworth,  and  proved  alarmingly  fatal. 

It  re-appeared  in  1507  and  again  in  1518,  when  the  epidemic 
was  extremely  violent. 

In  1529  it  appeared  in  England  for  the  fourth  time,  and  soon 
extended  to  the  continent,  and  overran  the  greater  part  of  Europe. 
The  last  outbreak  in  England  occurred  in  1551. 

After  an  interval  of  over  a  century  and  a  half  (1718),  miliary 
fever  re-appeared  in  France,  Italy,  Germany,  Austria  and  als» 
Belgium. 

In  1802  an  epidemic  appeared  at  IlOttingen,  in  Bavaria,  and 
ran  its  course  in  ten  days. 


uy  of  tho  vtiHicles 

I — milk  in  tiHunlly 
t  relievtul  by  the 


diflPHse,  miliary 

jK)afi"-<Biiig  nanny 

'  on  account  of  its 

lanitis  and  Bcnrlet 


9  an  acute  ff!  -ile 
curascribed,  k  iial 
ttended  with  h  igh 
nse  of  Buffocation, 
3sicular  eruption, 
fsquamation.  Its 
Iwlapses  are  com- 

canthema.    Sudor 


I  back  to  the  close 
irly  described  un- 

3SS." 

fter  the  battle  of 


len  the  epidemic 

.h  time,  and  soon 
er  part  of  Europe. 

If  (1718),  miliary 
Austria  and  alsa 

,  in  Bavaria,  and 


.¥' 


r 


.4^il.-~iA-. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


Ki  liii   12.2 

u    Hli 


PtiotDgraphic 

Sciences 

Corporation 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  IVIicroraproductions  /  Institut  Canadian  de  microreproductions  historiques 


"*^:-Hj  ^'-^^.-^^y^C  '■■'•}■■'  •■^^^lt■^"  ^•'-[■-i-^-r^'-- ' ; 


V, 


CLINICAL   HISTORY. 


'675 


It  prevailed  in  Italy  and  Germany  iix  1837-39,  and  in  Belgium 
in  1849. 

Miliary  fever  occurred  in  1830  and  1855  simultaneously  with 
epidemics  of  scarlet  fever  and  measles.  It  occurred  in  connec- 
tion with  cholera  in  1849-54. 

Etiology.— The  nature  of  the  exciting  cause  of  miliary  fever 
remains  as  yet  unknown. 

Epidemics  are  often  limited  to  single  places,  or  spread  only 
over  definite  areas.  They  prevail  mt)stly  daring  the  spring  and 
summer  months,  and  last  on  an  average  f lom  seven  to  fourteen 
days;  occasionally  they  continue  two  or  three  months.  In  some 
epidemics  from  one-fifth  to  one-tenth  of  the  whole  population  is 
attacked  by  the  disease. 

Like  typhoid  fever,  miliary  fever  attacks  the  strong  and  the 
vigorous.  It  affects  adult  life  mostly,  and  occurs  oftener  in 
women  than  in  men.  An  attack  affords  no  immunity  from  the 
disease,  even  during  the  same  epidemic. 

Clinical  History.— The  clinical  history  embraces  a  descrip- 
tion of  the  stage  of  invasion,  the  sweating  stage,  and  the  stage 
of  eruption  and  desquamation. 

The  Stage  of  Invasion.— The  prodromal  stage  or  stage  of  in- 
vasion lasts  from  two  to  three  days.  The  patient  complains  of 
excessive  irritation  of  the  skin,  thirst,  headache,  and  general 
lassitude.  There  is  generally  more  or  less  febrile  movement, 
and  not  infrequently  a  feeling  of  suffocation  preceded  by  a  sense 
of  oppression  at  the  epigastriiun. 

The  Sweating  Stage.— In  the  evening  or  during  the  night  of 
the  second  or  third  day,  the  second  stage  of  the  disease  is  ush- 
ered in,  usually  by  rigors,  seldom  by  a  pronounced  chill.  A 
profuse  and  persisvent  sweat  at  once  appears,  accompanied  by  a 
prickling  sensation  in  the  skin,  epigastric  oppression,  and  palpi- 
tation of  the  heart  with  precordial  pain.  The  temperature  rises 
rapidly  to  103"  Fahr.,  and  sometimes  even  to  105°  Fahr.  The 
pulse  quickens  to  130  or  140  beats  per  minute.  The  headache 
increases,  and  the  palpitation  of  the  heart  becomes  violent  and 
tumultuous.  The  respirations  become  rapid,  often  irregular, 
and  the  sense  of  suffocation  is  extreme.  The  urine  is  generally 
turbid,  scanty  and  high-colored,  and  there  is  great  tenderness  on 
pressure,  in  the  epigastrium.    After  these  symptoms  have  con- 


■HM 


MM 


r 


Jim  iBq!WiJI!'>.LJtl 


WIW 1  Wlill*ywW)WHBgB!Ji  ^  ^  ywg.  ■. 


870 


LECTURES  ON  FEVERS. 


tiiiiKHl  unabated,  or  have  displayed  a  teudency  to  irregular  exa- 
cerbations or  intermissions  for  three  or  four  days,  sometimes 
longer,  the  eruption  appears,  and  the  patient  enters  the  third 
stage. 

The  Stage  of  Eruption.— A.^  the  eruption  apperrs,  the  symp- 
toms of  the  preceding  stage  rapidly  abate.  The  rash  consists  of 
irregularly  shaped  spots  M'hich  sometimes  stud  the  skin  so  thickly 
as  to  resemble  the  eruption  of  scarlet  fever.  It  appears  first 
upon  the  neck  and  chest,  and  gradually  extends  to  the  back  and 
extremities.  After  a  few  hours  vesicles  appear  in  the  center  of 
the  spots,  and  rapidly  increase  in  dimensions  until  they  attain 
the  size  of  a  millet  seed  or  a  small  pea  The  vesicles  contain  at 
first  a  clear  fluid  which  gradually  becomes  opaque  and  yellowish. 
After  two  or  three  days  they  burst  or  dry  up,  and  form  crusts 
which  fall  off  in  scales,  within  twenty-four  liours.  Convalescence 
is  usually  protracted  in  consequence  of  the  great  debility  and 
emaciation.  In  some  severe  cases,  during  the  sweating  stage,  a 
tyi)hoid  condition  may  be  developed,  or  a  sudden  and  fatal  col- 
lapse may  occur. 

Complications  seldom  occur;  occasionally  either  bronchitis, 
pneumonia,  sore  throat  or  diarrhea  accompany  the  disease. 

Duration. — The  average  duration  of  miliary  fever  is  from  five 
to  eight  days.  Epidemics  last  from  seven  days  to  fhree  months 
or  longer. 

Morbid  Anatomy.— Miliary  fever  presents  no  characteristio 
anatomical  lesion. 

The  Wood  is  thin,  bright-red  during  life,  but  dark-colored  after 
death.  Hypersemia  of  the  lungs,  liver,  spleen  and  mucous  mem- 
brane is  generally  present.  Superficial  ulcers  are  sometimes 
met  with  in  the  region  of  the  ileo-csecal  valve.  The  cutaneous 
eruption  is  caused  by  the  hindrance  to  the  escape  of  the  sweat 
from  the  sweat  glands.  The  imprisoned  secretion  emerges  under 
the  epidermis  around  the  sweat  duct,  and  as  the  scales  become 
elevated  a  small,  clear  vesicle  is  formed. 

Differential  Diagnosis.— The  discrimination  of  miliary  fever 
from  other  affections — more  particularly  typhoid  fever,  measles 
and  dengue — having  some  points  of  resemblance  to  it,  is,  under 
ordinary  "circumstances,  unattended  with  diflEiculty.  The  profuse 
sweating,  the  prickling  of  the  skin,  the  intense  oppression  at  the 


"^'r?- 


■  \. 


icy  to  irregular  exa- 
ur  days,  sometimes 
ent  enters  the  third 

apperrs,  the  symp- 
riie  rash  consists  of 
d  the  skin  so  thickly 
r.  It  appears  first 
nds  to  the  back  and 
ear  in  the  center  of 
lis  until  they  attain 
B  vesicles  contain  at 
»aque  and  yellowish, 
xp,  and  form  crusts 
urs.    Convalescence 

great  debility  and 
he  sweating  stage,  a 
idden  and  fatal  col- 

y  either  bronchitis, 
ay  the  disease. 

ry  fever  is  from  five 
ays  to  fhree  months 

ts  no  characteristio 

it  dark-colored  after 
1  and  mucous  mem- 
ers  are  sometimes 
?^e.  The  cutaneous 
>scape  of  the  sweat 
tion  emerges  under 
)  the  scales  become 

ion  of  miliary  fever 
hoid  fever,  measles 
ance  to  it,  is,  under 
sulty.  The  profuse 
6  oppression  at  the 


CHAllT. 

CHART  X\ll.— Miliary  fever. 


877 


Nnture: 

Prevails  In  liinitod  epidemics. 

Stng'es: 

InvRHlon. 

Sweutlngr. 

Eruption  and  dcsciua- 
inatlon. 

Duration: 

Two  to  thrci'  (lays. 

Three  to  four  days. 

Three  to  four  days. 

Cntinu'oiis 
SurlHco. 

Excessive  irritation. 

Profuse  ami   p<'rslst- 

ent  sweiiliiiK:.      Hot 

skin. 

Kruption,  llrst  on 
neck  and  chest.    Pap- 
ules and  vesicles  last 

two  to  three  days. 

Nervous  Systeui. 

Headache. 

Intense  headaoho. 

I- 
11 

■   .■■-  - 

TonilM-rnture: 

Slight  fever. 

103"  to  105". 

PuUe: 

Accelerated. 

130  to  140. 

Heart: 

Preconllal  distress. 

Pnlpittttlon.     Precoi"- 
dlal  pain. 

lios|)iration: 

Suffocative  feoltntf. 

nnpld.    IrroBiilar. 
Suffocative  feeling. 

Digrestlve  Tract: 

Thirst.  Oppression  at 
epigaiitrlum. 

Nausea      Oppnisslon 
at  epigastrium. 

■ 

Urine: 

Turbid  and  scanty. 

High-colored.    Sup- 
pressed. 

Profuse. 

ProKnosis: 

Favorable  In  moderate  cases . 

Convalescence: 

Often  protracted. 

Uelapsas: 

Relapses  are  of  common  occurrence. 

mmmm 


WMI 


rMMW^ 


.1 


378 


LECTURES  ON  FEVEHS. 


epignHtrium,  the  precordial  pain,  the  feeling  of  suffocation,  nnrl 
the  peculiarity  of  the  eruption,  readily  distinguish  it  from  all 
other  epidemic  diseases. 

PrognosiH.— The  mortality  varies  in  different  epidemics;  its 
average  is  from  eight  to  ten  per  cent.  The  prognosis  is  generally 
favorable  when  the  disease  runs  a  regular  course  with  only  mod- 
erate severity.  It  is  unfavorable  when  the  temperature  is  high, 
the  sweating  profuse,  and  the'  sense  of  constriction  intense;  also 
when  violent  delirium,  convulsions,  coma  or  profuse  hemorrhages 
supervene. 

Death  most  frequently  occurs  in  the  sweating  stage,  during 
the  exacerbation  which  precedes  the  appearance  of  the  eruption. 
Treatment.— Principal    UemeAies.— Bryonia  is  the  main 
remedy  during  the  first  part  of  the  disease.     It  is  specially  indi- 
cated  if  typhoid  symptoms  threaten.    Aconite  will  be  needed 
when  there  is  great  nervous  excitement  and  marked  febrile  move- 
ment.    Cadus  will  often  relieve  the  palpitation  and  the  sense  of 
constriction  with  precordial  pain.     Arsenicum  is  called  for  if 
there  is  much  anxiety  and  restlessness,  with  burning  fever.    Ja- 
horandi,  sambucus  or  mercurius  should  be  thought  of  when  the 
sweating  is  very  profuse.     Ipecac  if  there  is  intense  dyspncea 
with  a  fainting  sort  of  nausea.    Apis  when  there  is  much  itch- 
ing, or  urinary  suppression  threatens.     Sulphur  during  desicca- 
tion, and  Cinchona  during  convalescence. 

Other  remedies  not  infrequently  of  service  are,  amm.  carb., 
ant.  crud.,  bapi,  bell.,  causi,  cham.,  convallaria,  digit.,  hepar 
sulph.,  hyos.,  lach.,  mez.,  nat.  mur.,  phos.,  polyporus,  puis.,  rhus 
tox.,  selen.,  sil.,  spig.,  sulph.  acid,  and  verat.  alb. 

The  patient  should  be  kept  in  bed  and  given  a  moderately  nu- 
tritious diet.  Frequent  sponging  of  the  surface  with  warm 
water  is  highly  beneficial.  Stimulation  may  be  needed  in  severe 
cases. 


L- 


\i'miiit0itmnimm..: 


iffocation,  nnd 
bU  it  from  (ill 


epidemics;  its 
jis  is  generally 
vith  only  mod- 
rature  is  high, 
n  intense;  also 
le  hemorrhages 

;  stage,  during 
)£  the  eruption. 

J  is  the  main 
I  specially  indi- 
(viil  be  needed 
)d  febrile  move- 
md  the  sense  of 
is  called  for  if 
ling  fever.  Ja- 
rhi  of  when  the 
itense  dyspnoea 
re  is  much  itch- 
during  desicca- 

ire,  amm.  carb., 
'ia,  digit.,  hepar 
orus,  puis.,  rhus 

I  moderately  nu- 
face  with  warm 
needed  in  severe 


LECTURE  XXV. 

Measles. 

Measles  is  the  most  i)nvalent  of  all  the  fevers. 
Definition.— It  may  be  defined  as  an  acute,  epidemic  conta- 
gious disease,  lasting  about  seven  days,  occurring  mostly  in 
early  life,  characterized  by  an  eruption  of  red  spots  resembling 
flea-bites,  which  coalesce  into  crescents,  accompanied  by  catarrhal 
symptoms,  more  or  less  fever,  and  general  constitutional  dis- 
turbance.    It  is  generally  unattended  with  danger,  but  is  espe- 
cially liable  to  be  followed  by  sequels.     It  rarely  occurs  a  second 
time  in  the  same  individual.     The  period  of  incubation  averages 
from  nine  to  twelve  days. 
Synonyms.— Rubeola.    Morbilli.    Rougeole.    Maseru. 
History.- Measles  invaded  the  world  about  the  same  time  as 
sn.ai-pox.    It  is  supposed  to  have  started  on  the  shores  of  the 
Red  Sea  during  the  fifth  or  six  century. 

It  was  described  by  the  Arabian  physician  Rhazes  in  the  early 
part  of  the  tenth  century.  The  term  rubeola  was  introduced 
somewhat  later  by  the  Latin  translators  of  Hali  Abbas,  who  de- 
scribed it  under  the  name  Hasba  or  Alhasbet 

Rhazes  and  Avicenna  taught  that  small-pox,  measles  and  scar- 
let fever  were  the  same  disease. 

Measles  was  first  distinguished  from  small  pox  by  the  Arabian 
physicians  of  the  twelfth  century.  Morton  viewed  measles  and 
scarlet  fever  as  products  of  the  same  miasm,  and  believed  Jihat 
they  stood  in  the  same  relation  as  distinct  and  confluent  small-pox. 
In  1670  Sydenham  carefully  restricted  the  term  morhilli— 
hitherto  used  in  describing  scarlet  fever  and  measles  as  one  dis- 

(379) 


>-jffi6E?»s*a^<*K««»«;-jutf#*im.*5S.sfe'te'^^ 


!* 


I 


380 


LEOTUBKS  ON  FEVERS. 


ease— to  measles,  mid  clearly  distinguished  the  latter  from 
smnll-pox.  Menslos  and  sciirlot  fnvor,  however,  continnod  to  bi' 
confounded  until  about  one  hundred  years  ago. 

Tho  first  re(!ordB  of  true  epidemics  of  measles  were  furnished 
by  Forest  in  1563. 

Etiology. — 1.  The  PredinpoHing  Cnmcs. — Measles  appears  at 
all  seasons  <jf  the  year,  and  affects  every  latitude.  Epidemics 
are  more  severe  during  the  winter  than  during  the  summer 
months. 

Meteorological  condUions  exert  little  influence  upon  measles. 
Low  and  damp  situations,  however,  are  supposed  to  favor  its 
prevalence  and  encourage  the  development  of  complications  and 
sequels. 

Age  exerts  considerable  influence  as  a  predisposing  cause.  It 
is  for  the  most  part  an  aflection  of  early  life,  being  most  fre- 
quent between  the  ages  of  two  and  five  years.  After  fifteen 
years  the  liability  to  the  contagion  diminishes  but  never  entirely 
disappears  among  those  who  are  not  protected  by  previous 
attack. 

Sex  exerts  little  influence.  The  statistics  of  measles  show 
that  males  are  more  frequently  attacked  than  females. 

Raee  and  nationality  have  but  little  influence.  The  suscepti- 
bility to  the  contagion  is  almost  universal.  Savages  have  some- 
times suffered  greatly  from  it. 

2.  The  Exciting  Cause. — Measles  is  caused  by  a  specific  poison, 
the  exact  nature  of  which  is  still  unknown.  Klebs  and  Keating 
describe  it  as  a  micrococcus.  It  is  found  in  the  mucous  secre- 
tions and  in  the  blood  of  individuals  suffering  from  it,  and  m-  v 
be  conveyed  by  inoculation.  It  may  be  carried  in  the  clothii.g 
and  in  fluids — which  act  as  fomites— f  rom  one  place  to  another. 
Measles,  therefore,  is  in  a  certain  sense  a  portable  disease.  It 
is  contagious  in  all  its  stages,  and  its  poison  is  more  tenacious 
than  that  of  either  small-pox  or  scarlet  fever.  As  a  rule,  a  per- 
son unprotected  is  more  certain  to  take  measles  than  is  an  un- 
protected individual  to  contract  small-pox  or  scarlet  fever  under 
similar  circumstances  of  exposure.  The  period  of  incubation 
varies  from  five  to  twenty  days— usually  it  extends  from  nine  to 
twelve  days. 


a.-aia,Siaaii:^iiji^-;.la».!:.«aic;,i,Ws^t-^ 


CLINICAL   HISTORY. 


nsi 


he  latter  from 
continnod  ti)  bi' 

were  furnished 


isles  appears  at 
e.  Epidemics 
g  the  summer 

I  upon  measles. 
3d  to  favor  its 
iplications  and 

sing  cause.    It 

}ing  most  fre- 

After  fifteen 

never  entirely 

I  by  previous 

measles  show 
ales. 

The  suscepti- 
;es  have  some- 

ipecifio  poison, 
i  and  Keating 
fnucous  secre- 
rn  it,  and  m.'  y 
a  the  clothii.g 
ce  to  another. 
!e  disease.  It 
lore  tenacious 
a  rule,  a  per- 
than  is  an  un- 
it fever  under 
of  incubation 
I  from  nine  to 


Clillicnl  History.-  The  olinicid  history  embracoH  n  despriptioii 
of  the  preramiitory,  oru[)tivo  and  dewiniiniiitivo  Htages. 

I'nmoiiHovii  Sldf/r.  At  tlit'  dose  of  the  period  of  iiicubntioii 
-11  period  without  fever,  and  free  from  local  symptoms-  the 
(liseuHe  sets  in  with  symptoms  resembling  those  of  ti  severe  ct)ld 
or  rather  an  attack  of  influenza.  The  patient  is  languid  nwd 
chilly,  and  complains  of  frontal  headache,  and  pains  in  ilio  baek 
and  limbs.  There  is  coryza  with  frequent  sneezing,  and  a  con- 
stant irritating,  watery  discharge  from  the  nostrils.  Febrile 
movement,  accompanied  by  irregular  chilly  sensations  and  shiv- 
ering soon  folloMs,  and  the  temperature  may  rise  to  102 '  l-'alir. 
or  104 '  Fahr.  The  eyes  are  injected  and  watery,  and  the  tears 
excoriate  the  face.  There  is  great  drowsiness  Avith  wandering 
and  screaming  at  night.  The  tongue  is  usually  furred,  the  ap- 
petite is  either  impaired  or  lost,  and,  in  some  cases,  nausea  and 
vomiting  occur.  The  bowels  are  either  naturjd  or  there  may  be 
slight  constipation  or  diarrhea.  There  is  slight  soreness  of  the 
throat  with  a  dry,  hoarse,  laryngeal  cough,  and  slight  dyspnoea. 
A  rose-colored,  punctate  redness  of  the  tonsils,  roof  of  the  mouth 
and  palate  is  frequently  observed  twenty-four  hours  before  the 
eruption  appears.  A  red  pjipule  is  often  observed  near  the  free 
border  of  the  uvula  several  days  before  the  rash  appears  upon 
the  skin. 

This  stage  lasts  from  three  to  five — usually  four — days.  Upon 
its  conclusion  the  eruption  appears,  usually  with  an  increase  of 
the  fever,  which  had  in  a  great  measure  abated,  and  an  eleva- 
tion of  the  temperature  to  103°  Fahr.,  or  even  106°  Fahr. 

The  Eruptive  Stage. — The  eruption  appears  usually  first  upon 
the  temples  and  forehead,  and  thence  extends  in  about  thirty 
hours  over  the  neck,  trunk  and  extremities,  appearing  latest  upon 
the  dorsum  of  the  hand.  At  first  it  presents  the  appearance  of 
minute,  round,  bright  rose  or  deep  red  spots,  not  unlike  flea-bites, 
varying  between  one-twentieth  and  one-fourth  of  an  inch  in  di- 
ameter. Scanty  at  the  beginning,  these  flat-topped  papules — 
for  such  they  rapidly  become — soon  become  numerous,  especially 
on  the  face,  and  are  often  crowded  together  in  patches  of  a  cres- 
centic  or  semi-lunar  shape,  with  normal  colored  skin  between 
them.  When  pressed  upon,  their  color  disappears,  to  return 
rapidly  from  the  center  to  the  periphenj,  when  the  pressure  is 
removed.     After  the'  eruption  has  existed  for  two  or  three  days, 


: : 


:■ 


882 


I,ECTURE8  ON   FEVEnS. 


■y 


it  l)0}i;inH  to  I'lulo,  first  fmin  tlio  fuco,  n\u\  Huccfissively  from  tlio 
neck,  flu'Ht  mid  «'xti'»'mitie8. 

Ah  tlm  riisli  iniikoH  its  appeurnnce,  the  Hkin  beconiPH  hot  and 
hwdUoii,  especially  on  the  face,  and  in  atten(h^d  with  more  t.i"  Ibhh 
itching  and  hurning.  Tlie  cory/a  increaseH,  the  fever  rJHeH,  and 
there  in  a  general  exacerljation  «)f  the  Hyniptoms.  The  pulse 
rangeH  fritni  100  to  140  or  even  100,  and  the  teraperatun^  may 
run  up  to  104"  Fahr.  or  lOO"  Fahr.  It  remains  at  102"  Fahr.  or 
lOIi'  Fahr.  in  ordinary  cases.  The  respirations  are  short  and 
Imrried.  Tlie  cough  continues  and  is  loud,  lioarse  and  frequent. 
It  has  been  tt^rmed  the  "  iron  couijh  "  of  measles.  Bronchial  rales 
are  frequently  seen  upon  the  physical  exploration  of  the  chest. 
The  irritation  of  the  eyes  continues,  and  not  infrequently  there 
is  conjunctivitis.  Tlie  tongue  is  covered  with  a  thick,  creamy 
fur  in  the  center,  but  is  clean  and  red  at  the  tip  and  edges.  The 
sore  throat  continues,  and  there  is  marked  redness  of  the  tonsils, 
pharynx  and  soft  palate.  The  urine  is  turbid  and  scanty,  and 
contains  urates.  The  duration  of  this  stage  is  from  three  to 
four  days. 

The  Stage  of  Desquamation. — After  the  eruption  has  reached 
its  height — usually  on  the  second  day — the  disease  remains 
nearly  stationary  during  the  balance  of  the  eruptive  stage,  and 
then  gradually  abates.  The  rash  now  begins  to  fade,  the  tem- 
perature declines  two  or  three  degrees,  the  pulse  lessens  in  fre- 
quency, and  the  catarrhal  symptoms  subside.  The  eruption,  as 
a  rule,  begins  to  decline  upon  any  part,  about  thirty-six  hour 
from  the  time  of  its  first  appearance  upon  that  part.  It  steadily 
disappears  from  above  downwards  in  the  order  in  which  it  first 
appeared;  not  infrequently  it  will  have  faded  from  the  face  and 
neck,  while  it  is  still  more  or  less  prominent  upon  the  extremi- 
ties. The  cuticle  desquamates  in  the  form  of  furfuraceous  or 
branny  scales  in  a  considerable  number  of  the  cases,  leaving 
yellowish-brown  pigmentations  of  the  surface,  where  the  ele- 
ments of  the  eruption  have  existed.  These  pigmentations  or 
stains  remain  a  variable  length  of  time,  and  are  gradually  re- 
moved by  absorption.  Desquamation  is  usually  accomplished 
in  from  three  days  to  one  week,and  is  often  scarcely  noticeable. 
Coincident  with  the  disappearance  of  the  eruption,  the  febrile 
movement  ceases,  and  the  patient  becomes  convalescent. 


■•"4 


iiiwiwrwinTiTrriim'  f  rirn  iimirirmriBii  -  -rmr-  -"— u 


lUHEUL'LAU  TYITH. 


'Mi 


lively  from  tlio 

'oniPH  hot  nnd 
th  iiioro  t  1'  leHH 
'ever  riwH,  and 
18.     'x'he   pulse 
npernture  iiiny 
t  102"  Fahr.  or 
are  short  aiul 
e  aiul  frequent. 
Bronchial  ralfiH 
on  of  the  chest, 
requently  there 
\  thick,  creamy 
nd  edges.    The 
is  of  tlie  tonsils, 
and  scanty,  and 
i  from  three  to 

tion  has  reached 
(lisepse  remains 
iptive  stage,  and 
;o  fade,  the  tem- 
e  lessens  in  fre- 

le  eruption,  as 
thirty-six  hour 
lart.  It  steadily 
in  which  it  tirst 
■om  the  face  and 
on  the  extrerai- 

f  urf  uraceous  or 
e  cases,  leaving 

where  the  ele- 
)igraentations  or 
re  gradually  re- 
ly accomplished 
rcely  noticeable, 
ion,  the  febrile 
alescent. 


Duration. — The  duration  of  the  disenso  varies  from  twolvo 
to  sixteen  days. 

Irr(>i;iilar  Types.— Anomalous  cases  of  meaHles  nif  infre- 
queutly  oct'ur  during  the  course  of  epidemics.  They  are  de- 
pendent partly  upon  the  intensity  of  the  poison,  ])artly  upon  the 
degree  of  physical  vigor,  and  partly  upon  tlie  hygienie  surround- 
ings. 

At  times  the  eruption  is  irreguhir  and  fitful.  In  mild  cases  it 
may  fade  in  a  single  night,  and  no  evil  consequences  result  from 
the  disapi)earance.  Occasionally  tin;  impules  are  small  in  size, 
few  in  number,  and  light  colored.  Tiio  order  of  their  appearance 
may  bo  i)artially  reversed,  so  that  instead  of  cropping  out  first 
npon  the  face  and  then  upon  the  trunk,  they  may  show  them- 
selves first  on  the  trunk,  and  afterwards  on  the  face.  Sometimes 
the  stains  after  desiccation  assume  a  livid  or  purplish  hue,  unat- 
tended by  malignant  or  dangerous  syni[)toms.  An  irregular 
variety  occasionally  juevails  epidemicfilly,  among  the  poorly 
nourished  and  badly  hygiened,  characterized  by  a  tendency  to 
ulceration  of  the  mucous  surfaces.  Cases  formerly  described  as 
presenting  catarrhal  and  febrile  symptoms  without  the  eruption 
— .  uheola  nine  criqiiione — were,  to  say  the  least,  very  doubtful 
cases  of  the  disease,  while  those  alluded  to  as  measles  without 
catarrhal  symptoms — rubeola  sine  caiarrho — Avere  in  all  proba- 
bility, simply  cases  of  roseola. 

Malignant  Measles. — This  irregular  type  of  the  disease  gen- 
erally prevails  epidemically;  occasionally  it  occurs  sporadically. 
It  is  commonly  known  as  "  black  measles,"  and  may  appear  in 
either  of  two  forms: 

1.  An  irregular  form  in  which  there  is  a  very  high  range  of 
temperature  from  the  beginning  of  the  attack.  There  is  usually 
great  restlessness,  dyspnoea,  and  dryness  of  the  tongue.  The 
eruption,  which  at  first  may  be  bright-red,  early  assumes  a  dark- 
claret  hue.  The  dark  color  of  the  eruption  is  due  to  the  changes 
in  the  blood  consequent  upon  the  high  temperature. 

2.  A  form,  called  by  some  hemorrhagic  measles,  in  which  the 
eruption  is  largely  composed  of  petechial  spots  scattered  over 
the  surface.  A  few  days  after  the  onset  of  the  fever  and  the 
appearance  of  the  eruption  as  in  the  ordinary  form  of  the  dis- 
ease, the  eruption  assumes  a  dark  color,  and  the  symptoms  take 


814 


LIX'TUIIES  ON   FEVEKW. 


on  n  typhoiil  olmriictcr.  Tho  tonguo  bocoinos  dry  niid  ^laxod  in 
tlio  (•••iitor,  HonU's  collect  upon  tlu>  t«'t!th,  jiiid  then'  iimy  1m>  vom- 
iting' mid  dinnlicii.  Tli(>  [u'cuIitiritieH  of  this  form  iiro  dopoudent 
upon  11  lit'iiiorrhii^ic  dintlit'HiH. 

In  t'ithcr  of  tliesc^  irronular  typoH  tho  j)ationt  may  dio  of 
exhaustion,  or  of  cuugetstiou  of  tlio  internal  organs,  or  from 
hemorrhages.  ' 

<'oni|>li(*utioiis  niid  Swiiiols.  Tho  most  important  complicu- 
tions  of  nieaslcH  are  seatod  in  tlie  respiratory  Hysteni. 

CapiUarij  broncliilis,  following  tho  ordinary  bronchial  catarrh 
of  tlie  disease,  is  most  apt  to  occur  in  young  «'liildren.  It  may 
develop  at  any  stage,  and  is  always  of  serious  import.  Tho 
great  danger  when  the  bronchitis  becom«>s  difluso  and  extends 
into  the  liner  tubes,  is  that  atelectasis  and  secomlary  lobular 
pneumonia  will  ensue,  and  destroy  the  life  of  the  patient  by  cut- 
ting off  extensive  areas  of  breathing  surface.  Capillary  t)ron- 
chitis  is  attended  with  increasing  dysi)n(ca,  lividity  of  the  face 
and  extremities,  and  great  prostration.  Crepitant  and  sub-crep- 
itant  rales  at  the  lower  portions  of  tlie  posterior  dorsal  regions, 
without  dxillness  at  iirfct,  and  with  increased  resonance  later,  usu- 
ally attend  its  ajjpearance.  In  children  under  three  years  of  ago 
capillary  bronchitis  generally  proves  fatal. 

Pncuuionid  may  occur  at  any  time  during  the  course  of  the 
disease,  but  is  not  liable  to  follow  after  the  eruptive  stage.  It 
is  always  attended  with  danger,  and  in  very  y(ning  Children  ia 
likely  to  prove  fatal. 

Caiarrhdl  lavjfitgitis  is  a  not  lancommon  complication.  It  is 
often  accompanied  by  pharyngitis  and  is  characterized  by  sore- 
ness of  the  larynx,  and  a  loud,  shrill,  ringing  cough. 

Aciife  miliary  inherculosis  not  infrequently  occurs  as  a  sequel 
of  measles  in  adults. 

ColUis  may  occur  as  a  complication  during  the  initial  stage  or 
at  the  beginning  or  close  of  the  eruptive  stage. 

Secondary  meningitis  may  occur  as  a  complication  during  the 
decline  of  the  rash. 

Conjunctivitis,  otorrhoea  and  suppuratioii  of  the  cervical  glands 
are  common  sequels  in  patients  who  have  a  strumous  diathesis. 


'I 
I 


iiiul  ^'1(1/0(1  in 

may  bo  voni- 

iiro  (lopoudent 

t  nifty   (lio  of 
[iiuti,  or  Ivuva 


tftnt  coniplictt- 
oni. 

nchial  cntarrh 

drcn.     It  nmy 

inii)()rt.     Tho 

0  ftnd  extends 
ludnry  lobular 
patient  by  cut- 
Japillary  bron- 
ity  of  the  face 

1  and  8ub-crep- 
doraal  regions, 
mce  later,  ixsii- 
ee  years  of  age 

course  of  the 
tive  stage.  It 
ing  Children  is 

ilication.     It  is 

erized  by  sore- 

gh. 

urs  as  a  sequel 

initial  stage  or 

ion  during  the 

cervical  glands 
mous  diathesis. 


CHART. 

cuAur  xvTir.    Mmxh-i^. 


n.9.') 


Nnturi-; 

fliwn: 

Kplilcmlf.         ContHKloUM.          I'iirtiilili>. 

I'li'inoiilliiry. 

Eru|itlvi'. 

l>l'SI|lll|ltlllli\  c 

Puratloii: 
(hcHl: 

Four  (Inyi. 

Four  to  six  days. 

Two  loll.x 
dayn. 

CiiukIi  ^riMl  II) 
diMuppcurti. 

lli'iMU  hliil  ciiliiir  h. 

"  Ircin  ( (luuli  " 
lliiai'scnt'Hi*. 

Skin: 
Thnmt: 

Hot  iukI  ilry 

Piipilliii'  cwsci-nlM.    First 
on  lai-c.    iii'liliiv. 

llriinny  »riilc» 
iO'liiiiK. 

Horothmnt.    KcildlHh 
punuta. 

Pharynwrltis.  Kcildlsh 
punctn. 

5? 

e 

•A 
0 

■! 

i 

Eyog  • 

Wulcry.     Iiiji'ctcil. 

Conjunctivitis. 

NOHo; 

Cory/a.    Hnooisinir. 

1  .  ■ 

0 
0 

! 

I.- 

Huud: 

nri.wMliicHK      Krontnl 
hi'iiiliicht'. 

Ui'tne: 

S(;iinty.     Hljfh-folorcd. 

TiinifUL': 

Moist.    White. 

Moist.   Cletin 

Stomach: 

'I'hirst.    Anorexia. 

Appi'titc  re- 
turns. 

Uowolg: 

Constipation. 

('(mstipiitlon  or 
dliirrhf-ii. 

Normal. 

Pulse: 

100  to  120. 

100  to  130  or  \m. 

Falls  to  nor- 
mal. 

Tcnipeiiuure: 

103O  to  104"  first  flay. 
Declines  '.'ml  and  :inl  day. 

lai"  to  107" 

Rapid  defer- 

VOSCCIICC. 

Compllcutions: 

Bronchitis.       Pneumonia.       Conjunctivitis.       Colltlg. 

Incubation: 

Ten  to  fourteen  days. 

uum  miyiiimmiBiB.,  i 


3S6 


LECTUllES   ON   FEVKBS. 


ANALYSIS  OF  CHART. 

The  NervouH  System.-  Chilly  scnsaiions  and  shirerinn  usu- 

jillv  usher  iu  the  attack.  ..  .  ^ 

Hm  ,0/,,-  is  a  pr..,m„ent  m,,l  e,uly  symptom.    Oppvessne 

JZlmr..  are  sCncely  over  abBenl,    Tl>ey  ertend  acres,  the 

hrnw  and  to  the  root  of  the  nose. 

z7ro";Ls  often  exists  during  the  pretaonitory  stage,  after 

Avhicli  the  patient  is  usually  restless  and  sleepless. 

^ZJons  sometimes  occur  at  the  onset  of  the  disease,  in 

children. 

Mild  delirium  is  not  uncommon. 

The  Respiratory  Tract.-A  more  or  less  e^ten«ive  layperjB- 
miaof  the  mucous  membrane  of  the  respiratory  tract  is  inva- 

^T^ferisToryzawith  general  catarrhal  symptoms.    The  rye. 
are  inlected  and  watery,  and  the  eyelids  are  swollen  -d-dd-ecl 
Thereisabundanfclachrymation.    Conjunamtis not infrequon% 
occurs  during  the  eruptive  stage.     Sneezing  is  frequent,  and  the 
d   cTirge  from  the  nose  is  abundant.      Epistaxis  sometimes 
occurs      Sore  throat  with  tickling  sensations  and  difficulty  in 
ruling  is  often  complained  of ,  and  i-^^  ^o -^— -^.^ 
the  pharynx  and  neighboring  parts.     Occasionally  m  the  pre- 
InLry  stage,  the  roof  of  the  mouth,  soft  palate  and  uvula, 
TxhibTt  minut^  rose-colored  puncta.     Hoarseness  is  common 
All  the  catarrhal  symptoms  are,  as  a  rule,  increased  m  intensity 
luring  the  development  of  the  eruption.     The  most  common 
period  for  tlie  occurrence  of  pulmonary  complications  is  the 

'"S^tta  prominent  symptom.  It  is  apt  to  be  frequent  and 
distressing,  and  is  harsh,  hollow  and  brassy.  Not  infrequently 
it  is  worse  towards  evening  and  at  night.  The  respirations  may 
he  hurried  and  short.  Sonorous  and  sibilant  or  mucous  and 
sub-crepitant  rales  are  frequently  detected  upon  both  sides  of 
the  chest  in  the  course  of  the  attack. 

The  Teiiiperature.-The  initial  or  prodromic  fever  in  mea- 
Bles  is  usually  complete  in  from  twelve  to  '^^'^^1^1^;^^' 
during  which  tinie  the  temperature  rapidly  rises  to  102.5  Fahr. 
or  lOr  Fahr.  The  height  attained  during  this  stage  is  an  index 
of  future  elevations,  which  tend  to  exceed  the  initial  rise  by 


_ig*'wa*^ 


TTing  usu- 

Dppressi*  e 
across  the 

stage,  a£ter 

disease,  in 


ve  hyperse- 
•act  is  inva- 

The  ryes 
d  reddened, 
iifrequently 
ent,  and  the 

sdinetimes 
difficulty  in 
immation  of 
r  in  the  pre- 

and  uvula, 
is  common, 
in  intensity 
ist  common 
tions  is  the 

'requent  and 
infrequently 
irations  may 
mucous  and 
)oth  sides  of 

ever  in  mea- 
-four  hours, 
102.5°  Fahr. 
e  is  an  index 
litial  rise  by 


ANALYSIS   OF  CHART. 

from  1°  Fahr.  to  2°  Fahr.  The  initial  rise  is  generally  followed 
by  ii  vapid  descent  the  next  night,  so  that  on  the  following  morn- 
ing tliG  temperature  seldom  exceeds  100°  Fahr.,  and  may  be 
normal.  The  fever  of  eruption  begins  with  renewed  rise  of 
temperature,  and  unlike  the  initial  fever,  has  only  temporary 
!•(  missicms  until  tlie  rash  is  fully  developed.  In  normal  cases 
the  maximal  temperattire  is  reached  in  from  twenty-four  to 
thirty-six  hours  after  the  beginning  of  the  eruptive  stage,  and  is  . 
contemporaneoiis  with  the  fullness  of  the  eruption.  In  otliera 
it  may  precede  the  acme  of  eruption,  on  account  of  some 
complication.  When  the  temperature  is  at  its  maximum,  tlie 
thermometer  in  the  axilla  may  register  106°  Fahr.  and  even 
higher.  Should  the  aome  begin  in  the  evening,  the  next  morn- 
ing remission  will  be  either  slight  or  missing. 

Defervescence  begins  usually  in  the  night,  as  the  eruption 
begins  to  decline,  and  runs  a  rapid  course,  the  temperature 
reaching  the  normal  on  the  second  morning.  At  times  it  is  pro- 
tracted by  bronchitis  and  other  complications.  Sub-normal 
temperatures  are  occasionaUy  observed  in  the  first  days  of  con- 
vale,  cence.  '  , 

The  Pulse.— The  pulse  ranges  from  100  to  120  beats  per  min- 
ute, and  in  young  children  may  reach  160  beats.  As  the  eruption 
passes  its  moximum  of  development  the  pulse  lessens  in  fre- 
quency, and  rapidly  returns  to  the  normal,  unless  quickened  by 
complications. 

The  Cutaneous  Surface.— The  skin  is  usually  hot  and  dry, 
and  during  the  eruptive  stage  there  is  more  or  less  swelling  of 
the  surface  with  itching  and  burning. 

The  ernpHm  of  measles  appears,  as  a  rule,  on  the  fourth  day. 
Exceptionally  it  is  met  with  as  early  as  the  second  day,  or  not 
discovered  until  as  late  as  the  fifth  or  seventh  day.  It  consists 
of  slightly  elevated  isolated  spots  of  a  bright  or  deep  red  color, 
varying  from  half  a  line  to  three  lines  in  diameter.  It  is  first 
seen  upon  the  face-temples  and  f orehead-and  gradually  spreads 
over  the  trunk  and  extremities.  It  requires,  in  most  instances, 
from  thirty-six  to  forty-eight  hours  for  its  full  development.  Its 
average  duration  is  from  four  to  six  days. 

The  course  of  the  measles  eruption,  is  as  follows:  at  first  the 
lesion  consists  of  little,  fine,  red  dots,  not  unlike  flea-bites,  which 


If 


388 


LECTUEES  ON  FEVERS. 


soon  deveUn^  into  true  papules  with  broad,  flat  summits.  After 
a  short  time  these  papules  become  numerous,  and  are  crowded 
together  in  irregularly  crescentic  patches.  The  skin  between  the 
patches  usually  presents  a  natural  appearance,  although  in  se- 
vere cases  when  the  patches  are  numerous,  the  whole  cutaneous 
surface  may  assume  a  deep  red  tint.  The  eruption  reaches  its 
acme  on  the  second  day,  and  remains  stationary  about  one  and  a 
half  or  two  days,  and  then  fades,  wholly  disappearing  about  the 
sixth  day  after  its  appearance.  The  time  which  elapses  between 
the  starting  point  of  the  period  of  incubation-the  moment  of 
contagion— to  the  maximum  of  eruption,  averages  about  htteen 
days  As  the  eruption  disappears  it  loses  its  bright  red  color 
and  becomes  a  yellowish-red,  which  gradually  fades  until  noth- 
ing but  a  staining  of  the  surface  is  left.  ?  y 

Desquamation  follows  the  disappearance  of  the  eruption.  It 
is  generally  fine  and  bran-like,  and  proceeds  from  above  down- 
wards. 

The  Digestive  System.— T/jc  iongue  is  generally  moist,  white 
and  somewhat  furred.  During  the  eruptive  stage  it  is  usually 
coated  in  the  middle,  but  red  at  the  tip  and  edges.  A  dry  tongue 
with  a  temperature  of  106"  Fahr.  or  107°  Fahr.  on  the  first  day 
of  the  eruptive  stage,  is  indicative  of  malignant  or  black  measles. 

The  nppdUe  is,  as  a  rule,  impaired  up  to  the  stage  of  decline 
of  the  eruption.  Thirst  is  commonly  present  Nausea  and 
vomiting  occur  in  the  early  stages  in  a  small  proportion  of  cases. 

Constipation  is  of  frequent  occurrence.  Slight  diarrhea,  last- 
ing from  one  to  three  days,  is  often  present  during  the  eruptive 

Colitis  with  inflammation  and  tumefaction  of  the  solitary 
glands,  occurring  during  the  stage  of  eruption,  is  indicative  of 
danger,  especially  in  young  children. 

Tlie  Urine.— The  urine  is  usually  diminished.  It  often  shows 
but  little  change,  but  is  commonly,  as  in  other  fevers,  concen- 
trated and  high  colored.  It  is  of  a  dark  yellow  color  in  the 
eruptive  stage;  not  rarely,  it  contains  traces  of  albumen. 

Morbid  Anatomy.— Measles  presents  no  characteristic  ana- 
tomical lesions,  other  than  the  changes  in  the  skin  and  mucous 
membranes. 


. ' .  .^ii  li>M(j"irt  WMP»* 


i 

^1 


-  itJWiiWMi.rBiiyiiimTrrtii 


ttfmimmm 


nits.  After 
ire  crowded 
between  the 
lough  in  e-j- 
le  cutnueous 
a  reaches  its 
at  one  nnd  a 
ig  about  the 
)8e8  between 
J  moment  of 
about  fifteen 
ht  red  color 
s  until  noth- 

n'uption.     It 
above  down- 


■  moist,  white 
)  it  is  usually 
A.  dry  tongue 

the  first  day 
(lack  measles. 
ye  of  decline 

Nausea  and 
•tion  of  cases. 
iarrhea,  last- 
[  the  eruptive 

the  solitary 
,  indicative  of 


!t  often  shows 
ivers,  concen- 
'  color  in  the 
lumen. 

icteristic  ana- 
1  and  mucous 


MORBID   ANATOMY. 


889 


The  blood  is  usually  thin  and  dark  colored,  and  is  deficient  in 
fibrin  and  red  corpuscles.  Klebs  found  the  micrococci  of  mea- 
sles in  the  blood  taken  from  the  hearts  of  infant  cadavers.  Drs. 
Braidwood  and  Vacher  found  highly  refractile  spherical  bodies  in 
the  breath  of  measle  patients,  aud  similar  bodies,  together  with 
rod-shaped  fiisiform  and  ovoid  bodies  in  the  corium,  lungs  and 
liver.  Dr.  Keating  found  micrococci  not  only  in  the  liquor  san- 
guinis, but  also  in  the  substance  of  the  white  corpuscles  in  the 
blood  in  malignant  cases. 

The  mucous  membrane  of  the  eyelids,  nose,  pharynx,  larynx, 
and  larger  bronchi  is  more  or  less  intensely  congested.  It  pre- 
sents a  reddish  or  slightly  blackish  appearance,  and  exhibits  the 
ordinary  anatomical  changes  of  acute  catarrh.  The  catarrh 
which  may  be  considered  pathognomonic,  is  usually  most  se- 
vere immediately  preceding  and  during  the  early  period  of 
eruption.  Micrococci  and  bacteriform  elements  have  been  ob- 
served in  the  nasal  mucus  and  in  the  catarrhal  secretions  of  the 
respiratory  tract. 

Evidences  of  capillary  bronchitis  and  catarrhal  pneumonia 
are,  not  infrequently,  found  after  death. 

The  eruption  of  measles  during  life,  is  papular.  In  its  early 
stages,  slight  hypersemia  at  the  orifice  of  a  hair-follicle,  with 
slight  swelling  from  effusion  of  plasma  is  observed.  Around  the 
hypersjemic  papule  a  roseolous  patch,  due  to  hypersemia  of  the 
papillary  body,  soon  appears.  In  form  the  patches  are  crescent- 
shaped,  their  outlines  are  sharply  defined,  and  their  color  is 
bright  red,  sometimes  shading  off  into  blue.  Not  infrequently 
each  patch  contains  several  papules,  and  then  the  early  papule 
usually  occupies  the  place  of  a  hair  follicle.  As  soon  as  the 
patches  have  reached  their  maximum  of  development,  their  color 
begins  to  fade.  The  pale-brown  stains  which  remain  after  the 
fading  of  the  rash,  are  due  to  changes  in  the  escaped  red  corpus- 
cles, and  may  be  visible  two  weeks.  No  traces  of  the  eruption 
can  be  found  on  the  dead  body. 

Congestion  aud  inflammation  of  the  colon  with  inflammation 
and  tumefaction  of  the  solitary  glands  sometimes  occur. 

The  spleen  is  somewhat  enlarged,  and  there  is  more  or  less 
extreme  congestiou  of  the  internal  organs. 


LECTITRE  XXVI. 

Measles.— (Continued.  ) 

Differential  Diagnosis.— The  direct  diaguosis  of  measles 
must  remain  more  or  less  doubtful,  until  the  eruption  appefirs. 
Of  diagnostic  importance  during  the  epidemic  prevalence  of  the 
disease,  are,  the  suffused  eye,  the  swollen  eyelids,  the  coryza  and 
sneezing,  and  the  frequent,  hoarse,  scraping  cough  with  fever, 
thirst  pain  in  the  frontal  sinuses,  and  the  appearance  of  a  punc- 
tated eruption  on  the  hard  and  soft  palate  fifteen  or  twenty  hours 
before  the  development  of  the  cutaneous  rash.  Ordinarily,  after 
the  eruption  has  come  out  fully,  the  diagnosis  is  not  difficult. 
The  diseases  for  which  at  first  sight  it  may  be  mistaken,  are. 
influenza,  scarlet  fever,  german  measles,  small-pox,  roseola,  ty- 
phus fever  and  the  erythematous  syphilide. 

The  main  points  of  contrast  between  mCLisles,  scarlet  fever, 
german  measles  and  small-pox,  are  arranged  in  a  tabular  form 
upon  pages  402  and  422. 

Roseola  and  measles  present  some  points  of  resemblance,  the 
most  important  of  which  relate  to  the  character  of  the  rash. 
The  eruption  in  measles  appears  on  the  fourth  day,  and  is  par- 
tially confluent.  It  is  preceded  and  attended  by  catarrhal  symp- 
toms, and  by  fever  which  runs  a  characteristic  course.  The 
eruption  of  roseola  appears  on  the  first  day,  presents  no  catarrhal 
symptoms,  and  is  attended  with  but  slight  fever.  Measles  is 
contagious;  roseola  is  non-contagious. 

The  differential  diagnosis  between  measles  and  typhus  fever 

may  be  found  on  page  291. 

Measles  maybe  differentiated  horn  the  erythematous  syphtlide 
by  the  glandular  changes  which  characterize  the  latter  disease. 
(390) 


I  jJHHi^ 


msmmimiim 


n 

t 

M 


TllEATMENT. 


391 


lis  of  measles 
iption  appefirs. 
3vnlence  of  the 
the  coryza  and 
gh  with  fever, 
mce  of  a  puiic- 
n-  twenty  hours 
irdinarily,  after 
is  not  difl&cult. 
1  mistaken,  are, 
)ox,  roseola,  ty- 

!,  scarlet  fever,. 
a  tabular  form 

^semblance,  the 
er  of  the  rash, 
clay,  and  is  par- 
catarrhal  symp- 
c  course.  The 
nts  no  catarrhal 
rex.    Measles  is 

id  typhus  fever 

matous  syx>hilide 
le  latter  disease- 


Prognosis. — The  prognosis  in  simple,  uncomplicated  cnnPH  of 
measles,  is  always  favorable.  In  malignant  cases  it  is  of  neces- 
sity grave.  Pregnancy  in  women,  and  dentition  in  children, 
render  it  unfavorable. 

The  conditions  for  a  favorable  prognosis  are:  when  tlie  disease 
is  primary,  Avhen  the  eruption  occurs  on  the  fourth  day  and  I'uns 
a  regular  course,  when  the  fever  is  moderate,  and  when  the 
cough  and  other  symptoms  diminish  with  the  fever. 

The  conditions  for  an  unfavorable  prognosis  are:  when  the 
disease  pursues  an  irregular  course,  when  the  symptoms  of  the 
premonitory  stage  are  violent  and  the  temperature  reaches  105° 
Fahr.  or  106"  Fahr.,  when  the  tongue  becomes  dry,  when  the 
eruption  becomes  livid,  when  the  fever  does  not  disappear  with 
the  eruption,  when  profuse  hemorrhages  from  the  mucous  sur- 
faces occur,  when  the  cough,  dyspnoea  or  diarrhea  continue,  or 
when  the  disease  occurs  in  a  patient  suffering  from  some  clironic 
disease. 

The  occurrence  of  any  of  the  more  serious  complications,  such 
as  capillary  bronchitis,  catarrhal  pneumonia,  colitis,  etc.,  always 
renders  the  prognosis  bad. 

The  mortality  of  measles  is  generally  slight,  except  during 
malignant  epidemics,  and  when  occurring  in  badly-nourished, 
cachectic  and  scrofulous  subjects.  It  is  much  greater  in  adults 
than  in  children.  When  death  occurs,  it  is  mostly  during  or 
after  the  second  week  of  the  disease. 

Treatment. — Prophylaxis. — Isolation  is  the  most  eflfective 
preventive  measure.  It  should  be  instituted  as  early  as  possible, 
and  continued  for  some  time  after  the  eruption  has  disappeared. 
At  least  one  week  should  elapse  after  the  fall  of  the  temperature 
to  the  normal,  or  after  the  entire  disappearance  of  the  rash,  be- 
fore the  patient  should  see  any  one  other  than  the  attendants. 
The  contagiousness  is  somewhat  diminished  by  frequent  bath- 
ing, and  by  night  and  morning  inunctions. 

Pulsatilla,  though  generally  recommended,  is  of  doubtful  effi- 
cacy as  a  prophylactic. 

Principal  Remedies. — Aconite  is  adapted  to  the  febrile  and 
catarrhal  symptoms  of  the  premonitory  stage.  It  mitigates  the 
fever,  and  allays  the  nocturnal  cough  and  feverish  restlessness. 
Qelsemium  is  indicated  when  the  eruption  is  slow  in  appearing. 


BiiMBiwiirtaBaiWMMiwuiiiiMifc iiiiirii—n— j—MJii^iaw 


■I 


392 


LECTU11E8  ON   FEVEBM. 


when  there  is  drowsiness  with  high  fever,  and  when  there  is  a 
tendency  to  convulsions.  Verairum  viride  is  needed  if  there  is 
muoh  cerebral  or  nervous  irritation  with  tendency  to  convulsions, 
or  if  congestion  of  the  lungs  threatens.  Belladonnai^  cc  use 
early  in  the  disease,  if  there  is  much  irritation  of  the  faKces  or 
larynx,  or  a  dry  spasmodic  cough;  also,  if  there  is  a  tendency  to 

delirium.  ,    ,  , 

Euphrasia  is  indicated  when  the  catarrhal  symptoms  are 
chiefly  nasal  and  conjunctival,  when  the  eyes  are  very  sore,  and 
when  there  is  profuse,  fluent  coryza.     Dry  cough  is  a  character- 
istic.   Kali  hyd.  may  be  useful  in  the  premonitory  stage,  when- 
the  catarrhal  symptoms  are  marked.    It  is  preferable  to  euphra- 
8ia  when  chest  symptoms  are  prominent.     Pulsahlla  is  mdicatetl 
when  there  is  dry  coryza,  and  when  there  is  marked  nervous 
irritation  in  the  early  days  of  the  eruptive  stage.     It  is  the  chiet 
remedy  when  gastric  symptoms  are  troublesome.    Bryonia  is 
needed  when  the  eruption  recedes  or  becomes  livid,  and  typhoid 
symptoms  appear.     It  should  be  given  early,  when  there  is  in- 
flammatory  irritation  of  the  bronchi.     Kali  hich.  is  suitable 
when  there  is  hoarse  scraping  in  the  chest,  or  when  simple  bron 
chitis  supervenes.    Phosphorus  is  called  for  when  pneumonic 
complications  exist,  especially  when  hoarseness,  di-y,  hacking, 
hollow  cough  with  raw  scraping  feeling  in  the  chest,  and  muco- 
Banguinolent  expectoration  are  present    Tartar  emct  is  useful 
for  either  the  bronchitis  or  the  pneumonia,  when  there  is  oppres- 
sion of  the  chest  with  difficult,  rattling  breathing.     Ipecac  may 
be  given  for  retching  and  vomiting,  and  for  teasing  cough  from 
tickling  in  the  throat  with  dyspnoea.    Bed  iodide  of  mercury  for 
glandular  swellings  and  for  obstinate  cough  during  convalescence. 

Gelsemium,  hryonia,  cuprum  acet.,  opium,  ipecac  and  ammo- 
nium carb.  are  the  principal  remedies  for  suppression  or  retro- 
cession of  the  eruption.  Arsenicum  is  the  main  remedy  in 
malignant  cases,  when  the  eruption  is  of  a  dusky  hue  and  there 
is  great  depression  with  blueness  and  coldness  of  the  surface. 
Secale  is  useful  in  low  putrid  states,  and  when  gangrene  threatens. 

As  intercurrents:  cofea  may  be  needed  for  wakefulness.  He- 
par  sulph.  for  wheezing,  or  slightly  loose,  croupy  night  cough. 
Spongia  for  dry,  croupy  cough  with  burning  in  the  larynx  and 
trachea.  Hyoscyamus  for  short,  dry,  titillating  night  cough. 
Eupaforium  perf.  for  loose,  nocturnal  cough  during  convales- 


mm» 


lUI  Ji^wMifiii  lr»'iW'iiT''«i''''"'**™™** 


LEADING   INDICATIONS. 


dien  there  is  a 
ided  if  there  is 
to  convulsions, 
lonnais  cc  use 
if  the  favces  or 
.8  a  tendency  to 

symptoms  are 
i  very  sore,  and 
I  is  a  character- 
ary  stage,  when- 
•able  to  euphra- 
Hlld  is  indicated 
narked  nervous 
It  is  the  chief 
le.    Bryonia  is 
rid,  and  typhoid 
rhen  there  is  in- 
ich.  is  suitable 
ben  simple  bron 
rhen  pneumonic 
8,  dry,  hacking, 
best,  and  muco- 
r  emct.  is  useful 
there  is  oppres- 
ig.     Ipecac  may 
sing  cough  from 
e  of  mercury  for 
ig  convalescence. 
»ecac  and  ammo- 
)ression  or  retro- 
main  remedy  in 
[y  hue  and  there 
s  of  the  surface, 
ttgrene  threatens, 
wakefulness.   He- 
ipy  night  cough, 
n  the  larynx  and 
ng  night  cough, 
during  convales- 


393 

Arsciiicnm  or  vcrat 


cence.    Mercuriua  cor.  for  dysenteric  stools 
o//>.  for  diarrhea.  _  v      *^, 

Silicea,  mereurius  and  heimr  are  most  important  remedies  for- 
otorrhcea.    Arsenicum,  mercuHns  cor.  and  hepar  for  ophthalmia. 
Suh^hnr  and  mercmiua  during  the  decline  of  the  eruption.    An- 
timonium  crtulum  during  convalescence,  when  the  appetite  doe^ 
not  return  and  the  tongue  remains  thickly  coated.     Cinchona  and 
phosphoric  acid  if  there  is  much  debility  during  convalescence. 
Leading  Imllcations.-Aconite.-High  febrile  excitement 
with  full,  hard,  quick  pulse.    Restless  sleep  with  jerking  and 
starting.    Distressing  pressure  at  tVie  root  of  the  nose  (rncm). 
Grating  of  the  teeth  {hell).    Short,  dry,  racking  cough  froin 
tickling  in  the  larynx,  with  or  without  oppression.     8t|t«l.'««  ;» 
the  chest  (6ny.).     Coryza  with  sneezing  (.snm/.).     Pain  in  the 
stomach  and  bowels  with  vomiting  and  diarrhea. 

Aminoiiium  carb.-Fluent  coryza  with  stoppage  of  the  nose 
Burning  water  runs  from  the  nose  {mere.  cor. ).    Roughness  and 
scraping  in  the  throat  {canst).    Cough  worse  after  midnight. 
Dyspnia  from  retrocession  of  eruption.    Child  starts  from  sleep, 
cannot  get  his  breath.    Adynamic  state. 

Antlmonium  crud.-Child  is  delirious  and  drowsy  with  hot, 
redface.  Redness  and  inflammation  of  the  eyelids  (were,  su^i)/*.). 
Tongue  coated  thick,  white  {bry.,  mere. ).  Gastric  derangements, 
{puis.).    Pains  in  the  ears. 

Apis  mel.-Confluent  eruption  and  oedematous  swelling  of 
the  skin  {ars.).  Eyelids  swollen,  red  and  edematous.  In- 
tensely deep,  red  rash  {hell).  Catarrh  of  the  bowels  with 
diarrhea.    Prostration,  muttering  and  delirium. 

Arsenicum.— Great  anxiety  and  restlessness.  Extreme  debil- 
ity with  dyspnoea  on  lying  down.  Frequent  sneezing  with  pro- 
fuse, watery  discharge  from  the  nose,  corroding  the  lips  and 
making  the  upper  lip  sore  {arum,  mere.  cor.).  Profuse  lachry- 
mation  and  burning  in  the  eyes  {acmUe).  Great  thirst  with 
chilliness  after  drinking.  Pale,  earthy  color  of  the  face.  Cough 
with  frothy,  tough  expectoration.  When  coughing  a  pain  ex- 
tends from  the  lumbar  region  down  into  the  thighs.  Diarrhea; 
the  evacuations  excoriate  the  anus  {mere. ).  Petechite.  In  ady- 
namic  cases. 


i 


WiMOiiiWiitMWnlHMlBli 


394 


LECTURES  ON   FEVERB. 


Bella«loiilia.— Constftnt  drowBy  sleep,  or  drowflitieRs  with  ina- 
bility to  go  to  Bleep.  SthVtliig  and  jiiinpiiig  during  sl^ep  with 
fliished  face  and  red  eyes.  Dryness  of  the  nose  with  dull,  fron- 
tal headache.  Fnquent  sneezing,  sore  throat  and  hoarsonosH. 
Dry,  8i)asmodic  or  hollow,  hoaree  cough,  ysrorse  at  night  (rfros.). 
Over-excitability  of  all  the  senses  {coffea).    Conviilsions. 

Bryonia. — Dry,  painful  cough  with  roughness  and  dryness  of 
the  larynx.  Great  dyspnoea  and  quick  breathing.  Congestion 
of  the  chest  with  shooting  and  stitching,  increased  by  doep 
breathing  {'phos.).  Urination  when  coughing  (cina).  Bheu- 
matic  i)nin8  in  all  the  limbs.  Retrocession  of  eruption  with 
prostration  and  fever.  Constipation.  Sitting  up  in  bed  causes 
nausea  and  faintness. 

Camphor. — Great  anxiety  and  restlessness  (ars.).  Suppres- 
sion of  eruption  (brij.,  cuprum).  Pale,  anxious  face.  Bluish- 
purple  color  of  the  skin.  Suffocative  dyspnoea.  Weak,  scarcely 
perceptible  pulse.  Sudden  and  great  prostration  with  spasmodic 
stiffness  of  the  body.  In  cases  assuming  a  malignant  form. 
Painful  and  difficult  urination  occurring  as  a  sequel  (apis). 

Carbo.  veg. — Pressive  headache  in  the  forehead  just  over  the 
eyes.  Painful  stitches  through  the  head  when  coughing  (hry.). 
Itching  on  the  margin  of  the  lids  (sulph.).  Violent,  almost 
constant  eructations  {puis.).  Persistent  hoarseness  {caust, 
phos. ). 

Cuprum  acet. — Nausea  and  vomiting,  relieved  by  drinking 
cold  water  (6ri/. ).  Sudden  retrocession  of  eruption  {amm.  carb., 
hry. ).  Epileptiform  convulsions.  Spasmodic  attacks  of  dysp- 
noea.    Blueness  of  the  face  and  lips  (lack.). 

Drosera. — Paroxysmal  cough  after  measles.  Constrictive 
pain  in  both  hypochondria  which  impedes  coughing.  Must  sup- 
port the  sides  with  the  hands  when  coughing  {eupat  p(^f.). 
Hoarseness  with  oppression  of  the  chest,  worse  from  talking 
{caust,  phos.).    Barking  cough  (rumex). 

Eupatorium  perf. — Coryza  with  sneezing,  hoarseness,  and 
aching  pains  all  over  as  if  bruised  {am.).  Headache  with  pain 
and  soreness  in  the  eyeballs;  photophobia.  Cough  with  retching 
{J. vs.).  Hacking  cough  in  the  evening  with  soreness  in  the 
chest  {caust);  must  support  the  chest  with  the  hands  when 
coughing  {dros.). 


4iiiiiiyiiMiMi«iMiii 


wmmmimm 


LEADING  INDICATIONS. 


395 


utiess  with  inn- 
•ing  Bleep  with 
with  dull,  froii- 
,nd  hoarsoiiesH. 
;  night  (dros.). 
ivulsions. 
and  dryness  of 
g.  Congestion 
reRsed  by  doep 
(cina).  Bheu- 
'  eruption  with 
3  in  bed  causes 

rs. ).  Suppres- 
face.  Bluish- 
Weak,  scarcely 
with  spasmodic 
lalignant  form, 
uel  (apis). 
\d  just  over  the 
mghing  (bry.). 
Violent,  almost 
seuess    {causty 

red  by  drinking 
on  {amm.  carb., 
ittacks  of  dysp- 

Constrictive 

ng.    Must  sup- 

(eupat  par/.). 

i  from  talking 

hoarseness,  and 
lache  with  pain 
h  Avith  retching 
soreness  in  the 
he  hands  when 


•  Enphrnsla.— Dull  frontal  headache  (mere,  puh.),  ProfuHe, 
fluent,  bland* coryza  with  scalding  tears  (opp.  ars.);  aversion  to 
light.  Burning  in  the  eyes  with  lachrymation.  Dry,  tickling, 
laryngeal  cougli  during  the  day,  relieved  by  eating  and  drinking. 

Oelseiiiiiini. — Chilliness  along  the  spine.  Sneezing  with  ting- 
ling, especially  in  the  left  nostril  {(jraph.).  Stoppage  of  the 
right  nostril;  irritating  discharge  from  the  left  nostril  with  scjild- 
ing  sensation.  Bruised  feeling  in  the  eyes  {bry.).  Shooting 
pains  in  the  ears  when  swallowing.  Sore  throat  with  collection 
of  mucus.  Kawness  of  the  chest  with  hard,  painful  cough. 
Great  drowsiness  during  the  fever.  Eetroceding  eruption  with 
livid  spots,  and  cerebral  symptoms. 

Hepar  snlph. — Intense  headache  above  the  nose  (mere). 
Darting  pains  in  the  ears  with  cracking  noises  when  blowing  the 
nose.  Feeling  as  of  sand  in  the  eyes  (stilph.).  Eoughness  and 
scraping  sensations  in  the  throat  (mix).  Cough  with  constant 
hoarseness.  Cough  caused  by  uncovering  any  part  of  the  body 
(rhus). 

Ipecacuanha.— Coryza  with  stoppage  of  the  nose.  Tardy 
appearance  of  the  eruption  with  oppression  of  the  chest  (puis.). 
Incessant,  dry,  titillating  cough,  with  rattling  of  mucus.  Much 
nausea  and  vomiting.    In  delicate  children. 

Kail  bich. — Frontal  headache,  usually  over  one  eye  (sang.). 
Lateral  headache  in  small  spots.  Fluent,  acrid  coryza,  excori- 
ating the  nose  and  lips  {arum,  mere.  cor.).  Flowing  of  water 
from  the  eyes,  with  burning  when  opening  them.  Stitches  in 
the  left  ear,  extending  into  the  neck  and  head,  with  swelling  of 
the  glands  {mere).  Battling  cough  with  viscid,  stringy  expec- 
toration.   Morning  hoarseness  {caust,  hepar). 

Kali  hyd. — Violent  sneezing,  and  running  of  acrid  water  from 
the  nostrils.  Sensation  of  fullness  and  tightness  at  the  root  of 
the  nose,  with  throbbing  and  burning  pains  in  the  nasal  and 
frontal  bones  {kali  bich.).  Burning  in  the  eyes  with  profuse 
lachrymation.  Rawness  in  the  larynx;  stitches  from  the  sternum 
to  the  back.  Short,  dry,  hacking  cough  with  whitish  and  green- 
ish expectoration. 

Lachesis. — Fluent  coryza  and  lachrymation  {ars.,  kali  hyd.). 
Throat  sore,  especially  when  touched  {apis).    Pain  in  the  left; 


.Laiiijiiii»w>i>niiiriwii>1iiiimiiiiimiiiiiiiiii ijaaeM 


396 


LECTURES  ON   FEVERS. 


ear  when  swallowing.  Dry,  spasmodic,  nightly  cough,  aggrn- 
vnU^tl  by  sleep.  The  eruption  api)ear8  slowly,  or  iMvun  black  or 
bluish.  Sorties  on  the  teeth.  Inability  t.)  protrude  the  tonjrne. 
Mercurilis.- Frequent  sneezing  with  profuse,  tluent,  corrosive 
coryza  {aru,„,  hnll  hud.).  Burning  in  the  eyes  and  profuse  fl..w 
of  tears.  InHamed  and  ulcerated  tonsils  ( hrll,  hrptir).  btitches 
in  tlie  right  side  oi  the  chest  when  sneezing  or  coughing  (br//.). 
Constipation,  or  mucus,  bilious  diarrhea.  Slimy  stools,  streaked 
with  blood.     Much  sneezing  without  relief. 

Niix  voiii.— Coryza  with  sneezing,  worse  in  the  morning  and 
after  eating.    Great  debility  with  over-sensitiveness  of  all  the 
senses  {cinch.).     Drowsiness  in  the  day-time  and  after  eating. 
Dry,  racking  cough  with  headache  as  if  the  skull  would  burst. 
Phosphorus.— Throbbing  headache;  headache  over  the  left 
eye  ( aco. ) ;  worse  in  the  evening.     Frequent  sneezing  with  alter- 
nately fluent  and  dry  coryza.     Difficult  hearing,  especially  <.f  the 
human  voice.    Hoarseness  and  roughness  of  the  voice  {cmist, 
hrpar).    Dry,  tickling  cough  with  tightness  across  the  chest, 
relieved  by  pressure  upon  the  external  walls.     Cough  worse  be- 
fore midnight,  and  from  reading,  laughing  or  speaking;  better 
after  sleeping  (opp.  loch.).     Mucous  rales  in  both  lungs,  espe- 
cially  the  lower  lobes  {iju'cc^,  lorlar  emct.).    Painless,  watery 
diarrhea.    Typhoid  symptoms  with  loss  of  consciousness. 

Pulsatilla.— Faent  or  drij  coryza  with  frequent  sneezing,  and 
loss  of  taste  and  smell  {sulph. ).  Inflammation  of  the  eyes  with 
profuse  lachrymation  {euph. ).  Darting,  tearing,  pulsating  pams 
in  the  right  ear  at  night  ( mere. ).  Eoaring  in  the  ears,  as  if  from 
the  rushing  of  waters.  Dry  cough  at  night  or  in  the  evening, 
especially  after  lying  down  {hyos).  Loose  cough  with  vomiting 
of  mucus,  and  nightly  diarrhea.  Gastric  disturbances  (niior). 
Chronic,  loose  cough  occurring  as  a  sequel. 

Rhus  tox.— Frequent,  violent,  spasmodic  sneezing.  Hot, 
acrid  discharge  from  the  nose.  Aching,  pressing  pains  in  the 
eves  (must);  oedema  of  the  lids  (apis).  Short,  dry  cough  from 
tickling  in  the  bronchi  {rnmcx).  Putting  the  hands  out  of  bed 
brings  on  the  cough  ( hcpar).  Great  restlessness,  must  change 
position  often  (opp.  brif. )■    Typhoid  symptoms. 

Sticta.-Incessant  sneezing,  with  a  feeling  of  fullness  in  the 
right  side  of  the  forehead  down  to  the  root  of  the  nose,  with 


'-.iMSMMI 


IW 


IP* 


HYOIENIO  AND   DTETETTC  TREATMENT. 


tm 


High,  nggrn- 
iniH  bliick  or 
3  the  tonjrne. 
ant,  corrosi'-o 
profuHO  flow 
r).  Stitches 
gliinR(/»7y.). 
x)l8,  streaked 

morning  and 
388  o!  all  the 

after  outing. 

wonhl  burst, 
over  the  left 
ng  with  alter- 
:)ecially  of  the 
voice  {cinist., 
jss  the  chest, 
ugh  worse  be- 
taking; better 
li  lungs,  espe- 
linless,  watery 
ausness. 

sneezing,  and 
:  the  eyes  with 
lulsating  i)ains 
;ars,  as  if  from 
1  the  evening, 

with  vomiting 
bances  {mix). 

leezing.  Hot, 
ig  pains  in  the 
iry  cough  from 
,nds  out  of  bed 
3,  must  change 

fullness  in  the 
the  nose,  with 


tingling  in  the  right  nostril.  Splitting  frontal  litMulacho.  Dry, 
racking  con<,'h  in  the  »noningaii(l  at  night,  oxcitcd  by  inspiratinii. 
Cougli  from  tickling  in  the  right  side  of  the  trachea,  with  op- 
pression of  the  chest.  Conjuuctivitia  with  profuse  but  niikl 
discharge. 

Ntrnilioilillin. — Frightful  visions  before  the  outbreak  of  the 
eruption.  Tries  to  escape,  struggles  to  get  out  of  bt'd  {lu'lL, 
rhns).  Dryness  of  the  throat  with  violent  thirst,  esi)ecially  for 
sour  drinks  (^»7/.).  Constant  restlessness  with  jerking  motions 
of  the  limbs  and  of  the  Avhole  body.  Difiicult  deglutition  from 
spasmodic  constriction  of  the  throat  {hell.,  Iiyos.). 

Sillpliur.— Coryza  with  stojjpage  of  the  nose.  Itching  and 
burning  in  the  nostrils,  as  if  sore.  Stitches  in  the  throat  when 
swallowing  {hell.).  Dry  cough  in  the  evening  on  lying  down, 
with  itching  in  the  bronchi.  Stitches  in  the  chest  extending 
back  to  the  left  scapula  {hdicarh. ).  Sudden  arrest  of  breathing 
when  turning  in  bed.  Chronic  cough  with  mucous  rales.  Chronic 
discharge  from  the  ears  with  hardness  of  hearing.  Chronic 
diarrhea. 

Tartar  eniet. — Chilliness  with  sneezing,  fluent  coryza,  and 
loss  of  taste  and  smell.  Much  rattling  of  mucus  in  the  chest 
{ipecac).  Cough  followed  by  yawning  {mix),  especially  in 
children.     Gastric  symptoms.     Cyanosis  {cuprum). 

Veratrum  alb. — Difficult  resjjiration  with  tightness  and  con- 
striction in  the  chest.  Deep,  hollow  cough,  occurring  in  shocks. 
Icy  coldness  of  the  forehead,  nose  and  extremities.  Tardy  and 
pale  livid  eruption.  Frequent,  weak,  intermittent  pulse.  Sud- 
den sulking  of  strength  {ars,).  Capillary  bronchitis  {bry., 
chcl,  tartar  eniet.). 

Veratriiiii  vir. — Severe  frontal  headache  with  vomiting. 
Restless  sleep  with  dreams  of  being  drowned.  Yellowish  or 
whitish  coating  on  the  tongue  with  a  red  streak  down  the  center. 
Violent  nausea  and  vomiting  with  pain  in  the  epigastrium.  Ir- 
regular, hard,  frequent  pulse.  The  heart  beats  rapidly  when 
turning  over  in  bed  {bell.).  Oppression  of  the  chest  with  slow, 
labored  breathing.     Convulsions  before  the  eruption. 

HYGIENIC    AND  DIETETIC    TREATMENT. 

The  patient  should  be  put  to  bed  and  kept  in  a  warm  and  even 


4j^»^s«#i.xariia»«s.*«»ft*««»»'^=^ 


^1 
I 


^m.: 


jj^g  LECTUHEH  ON    FEVFH" 

.  .    .  I"    i.vi,v  villi  70    I'nlir     mitil  UhmUh- 

opiu'iUHiuv  ..Ml."  011111"  "■  i,,   „„ 

"^';^.on  tho  Hkin  i«  a..y  an.l  hot    fvoquent,  warn,  ca^^ 
H,.on«o   baths.  f..Uowoa  by  caro!nl  .Iry.ng    «"'>.'"; '^T^; 
C        bathing  Hhouhl  bo  KiHhUously  ^uar.Unl  aKaumt  f  u  f.  -^ 
U)lti  naiiuub  n«  xi:,,i,*  n,„l  moniinu  immctioiw  with 

imlmonary  comphcations.     Niglit  ami  monm  k 

niiaiv  carboliml  eosnu.line.  ah.mml  oil,  or  a  pioco  «'[  ^varm  fat 

1'    l>r  wiouBly  Hoakod  n.  wator  to  remove  the  Bait),  t  ml  to 

L:al  the  fever  and  aiminish  the  ^f^^^"^^^ 

disease     The  ophthalmia,  when  marked,  may  be  i^l^^'.^'^^'l  '  ^ 

i  np  e  warm  water  or  milk  ami  water  lotions,  <.r  by  an  omtmeut 

:rvratr(veratriativet<>  seven  grains, 

Co    inhalations  are  of  service  when  l-y"^!'^^^ ^^^  ,«™X 
promiT^ant.    The  lung  complications  may  require  the  application 

"^Z:XS::ti:i^^:^  unstlmmating.     Chidcen  broth 
,„iik    mlk  and  arrowrtot,  and  warm  drinks  should  bo  given  at 
S^rtuntl^e  eruption  begins  to  fade.     Cool  drinks  ni  ..nail 
^1/"^.  maybe^allowedif  desired     ^hon  sym^^s  o    ex 
haustion  threaten,  either  brandy  or  sherry  >nne  and  egg     pre 
mred  bv  beating  up  a  raw,  fresh  egg,  and  stirring  with  it  one 
fabltpo^^^^^^^^  of'bi'ndy  or  two  tablespoonfuls  of  sherry  wine), 
or  beef  essence  (p.  190),  may  be  needed.  „i^tv,in„ 

During  convalescence,  to  avoid  taking  cold,  warm  clo  hing 
wifh  Hannel  next  to  the  skin,  should  be  woi..    Patients  sIk^uM 
remain  indoors  as  long  as  the  stage  of  desquamation  or  the 
cough  lasts. 


ultfUtfte 


mifmm 


mmm 


miiMPiM) 


mmm 


vintil  tlio  (lis- 
l)e  in(ulomt«'ly 
\  to  fivoul  <ill 
uld  ))t^  iiiHisted 

irm,  cnrbolized 
r  lia  of  service. 
inHt  foi'  ft  HV  of 
iuuijctioiw  with 
en  of  warm,  fftt 
0  suit),  tend  to 
imuuicnting  the 
l)o  relieved  by 
by  an  ointment 
nrate  one  ounce), 
il  Bymptoms  are 
3  the  application 

Cliicken  broth, 
lould  be  f,'iven  at 

drinks  in  Hinall 
symptoms  of  ex- 
ne  and  egg  (pre- 
rring  witli  it  one 

of  sherry  wine), 

I,  warm  clothing, 

Patients  should 

(juamation  or  the 


:  LECTURE  XXVII. 

Gorman  Measles. 

Deflnltloil.— German  measles  is  an  acute,  contngioiis,  eruptive 
disease  of  a  benign  nature,  occurring  in  general  or  li»>it»'d  epi- 
demics. It  is  chiiraott*!  j/,<d  by  irregular,  slightly  eleviiUvl.  hy- 
pericmic,  paleicjat*  red  blotches,  varying  in  size  from  a  pinw  Iwml 
t()  a  split  pea,  which,  M  ft  rule,  appear  suddenly,  and  in  light 
cases  disappear  within  two  or  three  days,  usually  with  but  slight 
desquamation.  It  is  attended  by  slight  sore  throat,  sliglit coryzii, 
and  but  little  ccmstitutional  disturbunce.  Its  average  duration 
is  from  five  to  seven  days.     Hocond  attacks  lira  exceedingly  rare. 

Hynoiiynis.— Botheln.  Hybrid  measles.  Mock  measles.  Epi- 
demic r(«eola.  Rubeohv  notha.  Scarlatiiia  morbilJosa.  French 
measles.     Hybrid  scarlatina. 

History.— German  measles  was  first  descrilxul  by  German 
writers  in  the  early  part  of  the  present  century,  under  the  name 
of  "  rubeola,"  by  which  name  it  is  still  known  in  Gevmnny. 

Cases  are  reported  as  having  occurred  in  Boston  in  Ih  !"),  in 
New  York  in  1873-74,  in  Philadelphia  in  1875,  and  in  German- 
town,  Pa.,  in  1878. 

A  wide-spread  epidemic  occurred  in  1880-81,  and  extended 
throughout  nearly  all  the  states  of  this  country.  During  this 
epidemic  the  disease  prevailed  extensively  in  New  York,  Chicago, 
Philadelphia  and  other  large  cities. 

Etiology.— The  nature  of  the  morbific  agent  of  german  mea- 
sles is  unknown.  Though  contagious,  it  is  not  as  much  so  as  is 
that  of  either  measles  or  scarlet  fever.  High  temperatures  are 
supposed  to  favor  its  development. 

(399) 


il 


400 


LECTUnES  ON  FEVERS. 


The  disefisc  belongs  essentially  to  childhood,  though  it  affects 
all  ages.  According  to  statistics,  it  is  much  more  prevalent 
among  females  than  among  males.  Its  type  is  not  constant  but 
varies  greatly  in  different  epidemics.  It  affords  no  immunity 
from  either  measles  or  scarlet  fever,  and  but  rarely  recurs 

Clinical  History.-  The  clinical  history  embraces  a  descrip- 
tion of  the  premonitory  stage,  the  eruptive  stage  and  the  desqua- 
mative stage. 

The  Premoniiorii  Stage. — In  mild  cases  after  an  incubation  of 
about  fourteen  days,  the  disease  is  ushered  in  with  the  eruj^tion. 
In  severe  cases  a  premonitory  stage,  which  is  of  from  twenty-four 
to  thirty -six  hours  duration,  and  is  marked  by  shivering,  febrile 
disturbance,  headache,  sore  throat,  pain  in  the  back  and  limbs, 
and  m  some  instances  by  nausea,  short  cough,  sneezing  and 
coryza  precedes  the  appearance  of  the  eruption. 

The  Eruptire  Stage. — The  eruption  consists  of  pale  red  or 
rosy  elevated  spots,  which  vary  in  size  from  a  pin's  head  to  a 
split  pea  or  larger.  It  usually  api^ears  upon  the  face,  neck,  and 
trunk,  and  sometimes  upon  the  arms  and  thighs.  At  times,  the 
pale  rose  red  color  is  perceptible  beyond  the  line  of  the  lesions 
in  the  form  of  a  delicate  halo.  When  large,  the  spots  are  gen- 
erally distinct,  and  are  seldom  arranged  in  ( rescentic  outline. 
When  small,  they  may  be  so  densely  crowded  together  as  to  re- 
semble the  eruption  of  scarlet  fever.  They  are  oftener  conflu- 
ent upon  the  face  than  upon  any  other  part  of  the  body,  and 
frequently  occasion  intense  itching,  After  remaining  visible; 
from  one  to  two  or  three  days,  they  rapidly  fade  and  disappear. 

The  constitutional  symptoms  which  attend  the  appearance  of 
the  eruption  are  usually  slight.  Sneezing  and  coughing  are  not 
infrequently  present.  Suffusion  of  the  eyes  with  injection  of 
the  conjunctiva  is  rarely  observed.  The  temperature  seldom 
rises  above  100.5 "  Fahr.  or  101.5°  Falir.  In  severe  cases  it  may 
reach  102  Fahr.  or  even  104°  Fahr.  Defervescence  usually  be- 
gins on  Aie  second  day  of  the  fever,  and  may  take  place  suddenly 
—by  crisis,  or  gradually — by  lysis.  The  pulse  usually  follows 
the  temperature.  The  fauces  are  generally  somewhat  congested, 
and  the  tonsils  may  be  moderately  swollen.  The  tongue  is  usu- 
ally covered  with  a  whitish  coating,  through  which  a  few  red  and 
enlarged  papillae  can  be  seen,  especially  at  the  tip.     Moderate 


mws 


•NW 


Jg!^g?l»'g<BWi!Wwwm'Mwwt«P-,'.i'f'*«M 


ough  it  affects 
ore  prevalent 
it  constant  but 
no  immunity 
y  recurs 

ices  a  (lescrip- 
id  the  desqua- 

i  incubation  of 
L  the  eruijtion. 
m  twenty-four 
vering,  febrile 
ck  and  limbs, 
sneezing  and 

jf  pale  red  or 
in's  head  to  a 
ace,  neck,  and 
At  times,  the 
)f  the  lesions 
spots  are  gen- 
;entic  outline, 
ether  as  to  re- 
ftener  conflu- 
the  body,  and 
aining  visible; 
nd  disappear, 
aijpearance  of 
ighing  are  not 
1  injection  of 
ature  seldom 
3  cases  it  may 
ce  usually  be- 
ilace  suddenly 
sually  follows 
lat  congested, 
;ongue  is  usu- 
a  few  red  and 
p.    Moderate 


CHABT. 

CHART  XIX.-German  Mmslcs. 


m 


Naturi". 


Iiu  libation: 


Kpl<lcmic.  Modoriuoly  contaiflous. 


Stiitres: 


Ton  fo  fuiirtcon  days. 


Premonitory. 


Eruptive. 


Duration: 


Eruption: 


Throat: 


Head: 


24  to  30  hours.         |    Ono  to  three  days. 


»  ~    .  .<  P'''"  ">80   red.  Doa- 

Appears  on  8nd  <lav.  sized  patches.  First  on 

baek  and  chest. 


Resquamallve. 


One  to  three  days. 


Small  scales.  Siijfht 
brown   stains. 


Slight  sore  throat,    'frlands  behind"8teino-|^'"'''  """>»*  gradually 
I     mfistoid  muscle. 


longun: 


Headache. 


Furred.    Marginal 
papillae  enlarged. 


Stomach : 


Pulse; 


Hespiratory 
tract. 


Nausea.    Anorexia. 


Slight  headache. 


Coated  white. 


Extremities:      Pain  In  back  &  limbs 


Accelerated . 


Byes: 


Temperature: 


Urine: 


Occasionally  catarrh- 
al symptoms      Dry, 
hacking  couirb 


Slightly  BUfTused. 


100"  to  103".    Highest 
on  1st  day. 


disappears. 


9 


Slightly  injected. 


Usually  declines  on 
2nd  day  of  disease. 


i 

o 

m 


K 

CD 


Defervescence  by 
either  crisis  or  lysis. 


Usually  normal.        Chlorides  In  excess. 


Prognosis: 


Duration : 


Recurrence: 


The  prognosiG  's  always  favorable. 


Five  to  seven  days. 


One  attack  Is  protective  against  recurrence. 


402 


LECTURES   ON   FEVERS. 


swelling  of  the  cervical  and  post-cervical  glands  occui's  iu  most 
cases. 

The  Desquamaiive  Siago. — The  eruption  commonly  fades  in 
from  one  to  two  or  three  days,  and  may  or  may  not  be  followed 
by  fine  branny  or  f urf uraceous  desquamation.  The  fading  f-x-up- 
tiou  sometimes  leaves  a  slight  brown  stain,  which  gradually 
disappears.  j-  « 

Duration. — The  average  duration  of  german  measxes  is  from 
five  to  seven  days. 

Morbid  Anatomy. — The  eruption  constitutes  the  principal 
anatomical  lesion  of  german  measles.  It  is  characteristically 
fugitive  in  character,  and  rarely  remains  visible  longer  than 
twenty-four  or  forty-eight  hours.  Exceptionally  it  continues 
visible  for  three  or  four  days.  Twelve  hours  is  the  limit  of  its 
most  marked  development. 

The  irregular,  light-red  spots  or  hypersemic  blotches  are  due 
to  capillary  hypersemia  of  the  papillary  layer.  They  are  usually 
distinct;  not  infrequently  they  are  crowded  together,  as  on  the 
face  and  trunk.  As  they  disappear,  very  faint  and  transient 
pigmentations  may  remain,  and  minute  epidermic  scales  may  be 
shed.  Occasionally,  vesicles  resembling  miliaria  make  their  ap- 
pearance upon  the  hyperasmic  spots,  especially  upon  the  back. 

Differential  Diagnosis. — The  differential  diagnosis  of  ger- 
man measles  is  usually  unattended  with  difficulty,  when  the  his- 
tory of  the  case  is  taken  into  consideration.  The  only  diseases 
with  which  it  may  be  confounded  are  scarlet  fever,  measles  and 
roseola. 

The  chief  characteristic  points  between  german  measles,  and 
scarlet  fever  and  measles,  are  shown  in  the  accompanying  table. 


MEASLES. 

Highly  contagious. 
Incubation,  7  (o  14  days. 
Stage  of  invasion,  3  days. 

Eruption  consists  of  pa- 
pules, arranged  in  cres- 
centic  patches. 


GERMAN    MEASLES. 

Moderately  contagious. 

Incubation,  10  to  14  days. 

Appearance  of  rush  often 
the  first  symptom. 

Eruption  consists  of  pea- 
sized,  slightly  raised 
patches. 


SCARLET  FEVER. 

Very  contagious. 
Incubation,  4  to  7  days. 
Stage  of  invasion,  2  days. 

Eruption  consists  of  mi- 
nute red  points,  on  a 
blight  red  hypertetuic 
ground. 


^ 


TUEATMENT. 


403 


occurs  iu  most 

monly  fades  in 
lot  be  followed 
be  fading  f-ray- 
hich  gradually 

aeasies  is  from 


»  the  principal 
laracteristically 
le  longer  than 
ly  it  continues 
the  limit  of  its 

(lotches  are  due 
'hey  are  usually 
ither,  as  on  the 
t  and  transient 
ic  scales  may  be 
,  make  their  ap- 
pon  the  back. 

agnosis  of  ger- 
f,  when  the  his- 
le  only  diseases 
3r,  measles  and 

in  measles,  and 
npanying  table. 

ABLET  PEVEB. 

contagious. 
)ation,  4  to  7  days, 
of  invasion,  2  days. 

tion  consists  of  mi- 
te red  points,  on  a 
ght  red  hyperaeiuic 
lund. 


MEASLES. 

Dull,  raspberry  red  color. 

First  appears  on  forehead 
and  face. 

Duration  of  eruption,  3 
days. 

Slight  sore  throat.  Dark, 
red  spots  on  palate. 

Glands  of  tbroat  not  en- 
larged. 

Tongue  furred  white.* 

High  fever,  with  general 
catarrhal  symptoms. 

Cerebral  symptoms  rare. 

Slight,  branny  desqua- 
mation. 

Becurrences  are  rare. 

Affords  no  immunity 
from  germau  measles. 


GEBMAM  MEASLES. 
Pale,  rose  red  color. 
First   appears   on    back 

and  chest. 
Duration  of  eruption,  2 

to  3  days. 
Slight  sore  throat. 

Enlargement  of  cervical 
and  post-cervical  glands 

Tongue  slightly  furred. 

Slight  fever,  with  or 
without  catarrhal 
symptoms. 

Cerebral  symptoms  ab- 
sent. 

Slight  desijuamation  in 
small  scales. 

Kecurrences  are  rare. 

Affords  no  immunity 
from  measles  or  scarlet 
fever. 


8CAELET   FEVEB. 

Bright  red  color. 

First  api)ear8  on  neck 
and  chest. 

Duration  of  eruption  un- 
certain. 

Inflammation  of  throat. 

Glands  of  throat  en- 
larged and  i)ainful. 

Strawberry  tongue. 

High  fever,  hot  skin, 
rarely  with  catarrhal 
symptoms. 

Cerebral  symptoms  fre- 
quent and  grave. 

Copious  dcs(]uamation  in 
large  flakes. 

Recurrences  are  rare. 

Affords  no  immunity 
from  german  measles. 


From  roseola,  german  measles  may  be  distinguished  by  the 
absence  of  coryza  in  the  latter,  and  by  the  glandular  enlargement 
which  occurs  in  the  tormer.  German  measles  is,  roseola  is  not, 
contagious. 

Prognosis.— The  prognosis  is  always  favorable. 

Treatment.— The  treatment  consists  largely  in  regulating  the 
diet,  and  in  protecting  the  patient  against  premature  exposure. 
Tepid  sponging  is  useful  in  allaying  the  annoying  itching,  and 
as  the  eruption  fades,  inunctions  of  the  surface  prove  beneficial 

Aconite  is  almost  the  only  remedy  required.  Belladonna  may 
be  of  service  if  the  throat  symptoms  become  marked.  Kali  bich. 
will  be  needed  when  hoarseness,  cough  and  catarrhal  symptoms 
are  present  Mercurim  may  be  used  for  the  swelling  of  the 
glands;  and  sulphur  during  desquamation.  (For  leading  indi- 
cations, consult  the  treatment  of  measles  and  scarlet  fever.) 


LECTUBE  XXVIII.     • 

Scarlet  Fever. 

Definition.— Scarlet  fever  is  an  acute,  epidemic,  contagious, 
eruptive  fever,  produced  by  poisonous  emanations— containing 
plaje  scindais—irom  an  infected  individual,  characterized  by  a 
scarlet  red  rash  on  the  body  and  extremities,  accompanied  witli 
fever  and  an  inflammation  of  tlie  throat.  It  runs  its  course  in 
from  seven  to  ten  days,  and  ends  by  desquamation,  which  usu- 
ally lasts  about  two  weeks.  It  chiefly  affects  children,  and  usu- 
ally occurs  but  once  in  the  same  person.  The  incubation  vanes 
from  three  to  eight  days. 

Synonyms.- Scarlatina  (from  "  gcarlatta,"  a  red-colored  cloth). 
Febris  anginosa.     Fothergill's  sore  throat.     Garotillo. 

History.— Scarlet  fever  is  supposed  to  have  invaded  the  world 
soon  after  small-pox  and  measles.  The  first  record  is  of  an  epi- 
demic angina  with  scarlet  eruption,  which  raged  in  Spain  in 
1610,  and  extended  to  Italy  in  1618. 

It  appeared  in  Germany  about  1625,  and  was  first  described 
in  England  by  Sydenham,  who  established  its  specific  nature 
in  1676.  In  its  mild  form  it  first  reached  Scotland  in  1680. 
Morton  described  it  as  appearing  in  London  in  1689. 

In  1735,  it  made  its  first  appearance  in  this  country  at  Kings- 
ton, about  fifty  miles  from  Boston.  Like  most  new  diseases,  it 
baffled,  for  a  time,  every  attempt  to  check  its  progress. 

In  1747-49  a  severe  epidemic  prevailed  in  London,  and  spread 
to  Plymouth  in  1751-53. 

In  1778,  an  epidemic  devastated  Birmingham. 

Itfij*st  appeared  in  Iceland  in  1827,  in  South  America  in  1829, 
in  Greenland  in  1847,  and  in  Australia  in  1849. 

(404) 


HMM 


ETIOLOGY. 


mr- 


lie,  contagious, 
jns — containing 
iracterized  by  a 
companied  witli 
ins  its  course  in 
ion,  which  usu- 
ildren,  and  usu- 
icubation  varies 

id-colored  cloth), 
jotillo. 

ivaded  the  world 
ord  is  of  an  epi- 
ged  in  Spain  in 

1  first  described 

I  specific  nature 

Botland  in  1680. 

1689. 

ountry  at  Kings- 

t  new  diseases,  it 

'Ogress. 

adon,  and  spread 


America  in  1829, 


During  tlie  last  twenty  years  it  has  prevailed  in  more  or  less 
extended  epidemics  in  this  country. 

It  appears  to  i)revail  to  an  unusual  degree  every  fifth  year. 

Etiology.  — The  causes  of  scarlet  fever  are,  predisposing  and 
exciting. 

1.  The  Predisposing  Causes. — The  srcison  of  the  year  appears 
to  exert  some  influence.  The  disease  may  prevail  at  all  seasons, 
but  is  most  frequent  in  spring  and  summer,  next  in  autumn,  and 
lastly  in  winter. 

A(f('  is  of  great  importance  among  the  predisposing  causes  of 
scarlet  fever.  The  greatest  susceptibility  is  between  the  ages  of 
three  and  five  years.  Children  under  two  years,  and  infants  at 
the  breast,  though  by  no  means  insusceptible,  are  rarely  affected. 
After  the  fifth  year  the  liability  rapidly  diminishes  and  becomes 
very  small  after  forty. 

Sex  exerts  little  influence  as  a  predisposing  cause.  Statistics 
show  a  marked  preponderance  in  the  number  of  males  attacked 
during  the  first  ten  years  of  life.  After  fifteen  years  of  age, 
females  are  more  susceptible  than  males.  As  contrasted  wiUi 
measles,  scarlet  fever  is  generally  lighter  in  proportion  to  the 
age  of  the  patient. 

2.  The  Exciting  Cause. — The  real  nature  of  the  scarlet  fever 
poison  is  no  longer  unknown.  Eklund's  discovery  of  minute 
organisms — plctx  scindens — in  the  blood  and  urine  of  scarlati- 
nous patients,  threw  a  flood  of  light  upon  this  subject.  Since 
the  announcement  of  his  discovery,  other  microscopists  have 
found  by  systematic  examination  of  the  blood  and  urine  of  scar- 
let fever  cases,  that  these  micro-organisms  are  constantly  present 
in,  and  peculiar  to,  the  fluids  of  this  disease.  As  contained  in 
the  urine,  Dr.  Eklund  describes  the  jjZoaj  scindens,  as  consisting 
of  flat,  oval  or  rounded,  colorless  or  yellowish-white  sporoidal 
cells,  having  a  distinct  cell  wall,  and  a  clear  brownish-colored 
nucleus.  As  a  rule,  they  are  found  free,  and  never  arrange  them- 
selves either  in  swarms  or  in  rows  as  do  ferments.  They  multi- 
ply by  binary  fission,  and  frequently  exhibit  rotary  or  screwing 
motions. 

Up  to  the  present  time  plax  scindens  have  not  been  found  in 
any  other  fever.  The  conclusion  is  inevitable  that  this  parasite 
has  to  do  with  th»  causation  and  development  of  scarlet  fever; 
or,  in  other  words,  that  it  constitutes  the  contagion  of  the  disease. 


i 


406 


LECTURES  ON  FEVERS. 


Tho  contagiousness  of  scarlet  fever  is  clearly  demonstrated  by 
both  clinical  (observation  and  experimental  inoculation.  MiqiK'l, 
Stole  and  Williams  have  succeeded  in  artficially  infecting 
healthy  individuals  by  inoculating  them  with  either  the  blood  or 
the  epidermic  scales  taken  from  scarlatinous  patientp.  These 
inoculations  were  followed  not  only  by  the  characteristic  febrile 
eruption,  but  were  more  severe  than  the  ordinary  disease,  and 
appeared  to  confer  a  certain  degree  of  protection  from  remocu- 
lation. 

The  period  at  which  the  disease  is  most  contagious  is  at  tho 
height  of  the  fever,  when  the  parasite  is  found  in  greatest  quan- 
tity in  the  urine.    It  may  also  be  conveyed  during  the  desqua- 
mative period  in  the  epidermal  scales.     The  atmosphere  may  be 
contaminated  not  only  by  the  air  exhaled  by  scarlet  fever  pa- 
tients, but  also  by  the  secretions,  especially  the  urine,     ihe 
distance  to  which  the  poison  may  be  carried  by  the  air  does  not 
exceed  a  few  feet    It  enters  the  system  mainly  by  the  lungs, 
although  drinking  milk  which  has  been  diluted  with  water,  prob- 
ably containing  plax  scindens.  may  cause  the  disease.   The  most 
frequent  mode  of  infection  is  by  breathing  the  air  of  a  room 
occupied  by  a  scarlet  fever  patient.    It  may  also  take  place 
without  direct  communication,  and  persons  may  carry  scarlet 
fever  to  others  without  becoming  affected  themselves.    In  order 
to  thus  convey  the  poison  it  is  necessary  that  the  clothing  be- 
come thoroughly  saturated  with  it,  and  physicians  m  simply 
making  their  daily  visits  are  in  no  danger  of  carrying  the  disease. 
It  retains  its  vitality  for  a  long  time,  and  may  attach  itself  to 
clothing,  bedding  or  furniture,  which  act  as /ornt/es. 

The  contagion  of  scarlet  fever  is  less  tenacious  than  that  of 
either  measles  or  small-pox.  Prolonged  exposure  to  moderately 
dry  heat  (204°  Fahr.)  destroys  it. 

The  period  of  incuhatim  is  shorter  than  in  the  other  eruptive 
fevers,  and  varies  from  two  to  ten  days.    Its  average  durationis 

from  four  to  seven  days.  •  . 

Immunity  from  a  second  attack  is  enjoyed  by  a  majority  of 
persons  who  have  suffered  from  scarlet  fever.  Nevertheless, 
many  cases  of  well-marked  second  attacks  are  recorded.  Sec 
ondary  or  tertiary  attacks  are  rarely  fatal. 

The  lower  animals,  especially  the  cat,  dog,  horse  and  hog,  are 
Uable  to  have  scarlet  fever.    Many  cases  occuiTing  in  the  human 


■—        (  fiinjwif^iji 


CLINICAL   HI8T011Y. 


■£07 


Bmonstrated  by 
ation.  Miquel, 
lially  infecting 
ler  the  blood  or 
ntientp.  These 
cteristio  febrile 
vry  disease,  and 
I  from  reinocu- 

tagious  is  at  the 
1  greatest  quan- 
mg  the  desqua- 
losphere  may  be 
carlet  fever  pa- 
;he  uriue.    The 
the  air  does  not 
ly  by  the  Kings, 
vith  water,  prob- 
sease.   The  most 
le  air  of  a  room 
also  take  place 
nay  carry  scarlet 
selves.     In  order 
the  clothing  be- 
icians  in  simply 
rying  the  disease. 
Y  attach  itself  to 
nites. 

ious  than  that  of 
ire  to  moderately 

he  other  eruptive 
rerage  duration  is 

by  a  majority  of 
)r.  Nevertheless, 
B  recorded.    Sec- 

lorse  and  hog,  are 
ring  in  the  human 


subject,  and  heretofore  supposed  to  have  originated  dc  novo  or 
iiidepeudent  of  infection,  were  jirobably  due  to  transmission  of 
the  disease  from  these  animals. 

Forms. — Scarlet  fever  may  be  either  mild  or  severe. 

1.  The  mild  or  ordiimry  form  represents  the  general  course  of 
the  disease,  and  will  1k>  fully  described  in  the  clinical  history. 

2.  The  severe  or  maliynant  form  is  characterized  either  by  tlie 
extreme  gravity  of  the  throat  symptoms,  or  by  the  early  involve- 
ment of  the  cerebro-spinal  system  in  consequence  of  some  i)ecu- 
liarity  of  the  morbific  agent,  high  temperature,  septic  or  ursomic 
poisoning,  or  extreme  susceptibility  of  the  organism. 

Clinical  History. — The  clinical  history  embraces  a  descrip- 
tion of  the  stage  of  invasion,  the  stage  of  eruption,  and  the 
stage  of  desquamation. 

The  Stage  of  Invasimi.— The  prodromal  stage  or  stage  of  in- 
vasion is  usually  usJiered  in  suddenly,  by  a  chill  or  chilliness, 
alternating  with  burning  heat,  followed  by  a  rapid  rise  in  tem- 
perature, which  often  reaches  104°  Fahr.  within  twelve  hours. 

The  skin  becomes  exceedingly  dry  and  pungent,  the  face 
flushed,  and  the  pulse  rapid  and  bounding.  Pain  in  the  head, 
vomiting  and  thirst  are  early  and  prominent  symptoms.  The 
tongue  is  thickly  coated  white,  the  filiform  papillae  are  enlarged 
and  project  through  tlie  coating,  and  the  whole  presents  the  appear- 
ance of  a  white  strawberry.  There  is  a  diffuse  redness  of  the  pil- 
lars  of  the  fauces,  uvula  and  tonsils,  with  slight  soreness  of  the 
throat  The  eye  assumes  a  peculiar  brilliant  and  glistening 
stare.  In  children  there  may  be  syncope,  delirium  or  convul- 
sions. The  average  duration  of  this  stage  is  from  twelve  to 
twenty-four  hours;  it  may  be  prolonged  to  four  or  five  days. 

The  Stage  of  Eruption.— TJBnaWy  on  the  second  day  of  the 
fever  an  eruption  appears  about  the  neck  and  clavicular  regions, 
and  extends  rapidly — within  ten  or  twelve  hours— over  the  en- 
tire surface  of  the  body.  It  is  first  seen  as  minute  red  dots  or 
specs,  which  vary  in  size  from  a  line  to  a  line  and  a  half  in  di- 
ameter. These  dots,  which  are  no  1  elevated  above  th%*  surface, 
run  together  and  form  patches  which  rapidly  coalesce. 

After  the  second  day  of  the  eruption,  the  whole  cutaneous 
surface  presents  a  bright  rose  red  appearance  in  mild  cases,  and 
a  deep  red  or  boiled  lobster  appearance  in  severer  cases.     The 


408 


LECTURES  ON   FEVERS. 


rasli  is  usually  most  intense  upon  the  back  and  loins.  Upon  the 
extensor  surface  of  the  limbs  it  is  often  developed  in  punctate 
form,  and  imparts  to  the  skin  a  certain  degree  of  roughr.esH. 
The  redness  which  momentarily  disappears  on  pressure,  rapidly 
returns  from  the  jteriphcry  io  the  cenler  of  the  spot,  the  instant 
the  pressure  is  removed.  As  the  eruption  becomes  fully  devel- 
oped, the  skin,  especially  on  the  face,  hands  and  feet,  appears 
slightly  swollen.  Frequently  there  is  more  or  less  itching  and 
burning  over  the  entire  surface.  Th*^  eruption  usually  attains 
its  maximum  of  development  upon  the  evening  of  the  fourth 
day  and  remains  visible  six  days.  In  extremely  mild  cases  it 
may  not  last  longer  than  two  or  three  days. 

The  febrile  and  other  symptoms  which  preceded  the  eruption 
persist  unabated,  and  are  often  augmented.  The  temperature 
may  continue  to  rise  until  it  has  reached  106''  Fahr.  or  107° 
Fahr.— usually  not  higher  than  103°  Fahr.  or  105°  Fahr.  The 
pulse  is  quick,  full  and  vibratory,  and  ranges  from  120  to  140  or 
even  160  per  minute.  Vomiting  becomes  more  severe  and  is 
projectile  in  character.  Thirst  is  usually  urgent  and  anorexia 
is  generally  present.  The  skin  is  dry,  and  the  heat  is  intense 
and  pungent.  The  condition  of  the  fauces  is  characteristic.  In 
some  very  mild  cases,  there  is  simply  redness  over  the  tonsils, 
pillars  of  the  soft  palate  and  uvula.  In  most  cases  there  is  more 
or  less  parenchymatous  inflammation  of  the  tonsils  with  general 
tumefaction  of  the  soft  parts  of  the  throat  Occasionally  ulcer- 
ation of  the  tonsils  takes  place.  Not  infrequently  the  glands 
about  the  neck  are  somewhat  swollen  and  tender.  The  tongue, 
which  early  in  the  disease  is  generally  coated,  may  shed  its  coat- 
ing and  appear  clean  and  reddened,  the  enlarged  papillae  giving 
to  it  the  so-called  "  strawberry  "  or  "  cat's  tongue  "  appearance. 
The  urine  is  scanty  and  turbid,  often  high-colored,  and  is  defi- 
cient in  chlorides;  occasionally  it  contains  albumen  and  bile 
pigment  Not  uncommonly  there  is  some  delirium,  especially 
at  night.  The  duration  of  this  stage  varies  from  four  to  six 
days;  it  may  be  prolonged  to  eight  or  ten  days.  Usually  from 
the  fifth  -to  the  eighth  day  of  the  eruption,  as  the  rash  fades, 
—leaving  a  brownish-yellow  pigmentation  of  the  surface — the 
temperature  begins  to  decline,  the  pulse  lessens  in  frequency,  the 
redness  aud  swelling  of  the  tonsils  diminish,  the  throat  symp- 
toms abate,  and  the  tongue  gradually  returns  to  its  normal  state. 


"«««« 


MALIGNANT  HOAHLET  FEVKR. 


m 


ns.  Upon  the 
d  in  pimctate 
of  roughr.esB. 
388ure,  rapidly 
»ot,  the  instant 
es  fully  devel- 
l  feet,  appears 
38  itching  and 
UBually  attains 
of  the  fourth 
r  mild  cases  it 

id  the  eruption 
lie  temperature 
Fahr.  or  107° 
15°  Fahr.     The 
a  120  to  140  or 
I  severe  and  is 
t  and  anorexia 
heat  is  intense 
racteristic.    In 
srer  the  tonsils, 
is  there  is  more 
ils  with  general 
asionally  ulcer- 
ntly  the  glands 
r.     The  tongue, 
ay  shed  its  coat- 
l  papillae  giving 
,e"  appearance, 
red,  and  is  defi- 
umen  and  bile 
•ium,  especially 
;rom  four  to  six 
,     Usually  from 
the  rash  fades, 
he  surface — the 
n  frequency,  the 
le  throat  symp- 
its  normal  state. 


The  Stage  of  Drsqunmaiion. — Desquamation  often  commences 
with  the  decline  of  the  eruption,  and  is  usually  plight  or  exten- 
sive in  proportion  to  the  intensity  and  diffusion  of  the  rash.  It 
commences  first  on  the  neck  by  a  loosening  of  the  epidermis  in 
the  form  of  thin,  light  scales,  and  gradually  extends  over  the 
whole  body.  On  the  extremities  it  is  frequently  exfoliated  in 
large  flakes.  Occasionally  the  cuticle  of  the  hands  and  feet  is 
detached  entire.  The  iiairs  may  be  simultaneously  shed.  The 
mucous  membrane  also  participates  in  the  exfoliating  processes. 
During  this  stage  the  urine  becomes  abundant  and  pale,  and 
often  contains  albumen.  The  period  of  desquamation  lasts  from 
ten  to  sixteen  days,  at  the  end  of  which  time  if  neither  compli- 
cations nor  sequels  occur,  the  patient  is  convalescent. 

Duration. — The  duration  of  scarlet  fever  in  uncomplicated 
cases,  is  from  two  to  four  or  six  weeks. 

Severe  or  Malignant  Scarlet  Fever. — The  severe  or  malig- 
nant form  of  scarlet  fever  is  usually  marked  by  irregularities  in 
the  manifestations  of  the  disease.  In  some  cases  the  symptoms 
set  in  suddenly  and  are  of  a  most  violent  character.  In  others, 
grave  symptoms  do  not  appear  until  the  third,  fourth  or  fifth 
day.  In  the  majority  of  instances  more  or  less  severe  and  dan- 
gerous symptoms  develop  during  or  immediately  following  the 
onset  of  the  attack. 

In  one  class  of  cases,  marked  by  early  high  temperature,  there 
is  not  much  swelling  of  the  throat,  nor  very  marked  increase  in 
the  frequency  of  the  pulse,  but  on  the  second  day  of  the  erup- 
tion the  thermometer  in  the  axilla  registers  107°  Fahr.  or  108" 
Fahr. 

In  another  class  of  cases,  the  throat  symptoms  are  promi- 
nent from  the  onset  of  the  attack.  The  fauces  are  of  a  deeper 
color  and  more  swollen  than  in  the  ordinary  form,  and  there  is 
more  difficulty  in  swallowing.  Whitish  or  yellowish  ash-colored 
points  or  patches  appear  upon  the  soft  palate  and  tonsils.  Those 
membranous  spots  may  remain  from  one  to  three  or  four  days 
and  then  disappear,  or  they  may  form  in  successive  crops.  The 
mucous  membrane  underneath  may  be  red  and  swollen,  or  even 
softened  and  ulcerated.  There  is  usually  more  or  less  fetor  of 
the  breath.  Occasionally  the  tonsils  are  enlarged,  infiltrated 
with  pus  and  softened.    The  pharynx  may  appear  ulcerated,  and 


i 


410 


LECTUUEH  ON  FEVEIW. 


in  vnry  miiliRnnnt  attnckw  iiifiy  jJioHont  evidonnos  of  ganRrene. 
Inrimniniition  uiul  HW«>llinf,'<»f  tlio  Hub-iimxilliiry  lymplmtic  glmulH 
and  Hurroundinji;  collular  Uhsuo  alnumt  invariahly  occnrw.  In 
favorable  caHOH  tlio  enlargement  and  induration  of  the  glands 
disappear  in  from  tlirec  to  twelve  lays,  in  (»tiierH  it  terminates 
in  snjjpuration.  Purulent  or  mendiranous  coryza  and  often 
otorrlicoa,  which  is  apt  to  result  in  permanent  deafness,  are 
present. 

In  still  another  class  of  cases  the  patient  may  perish  shortly 
after  the  onset  f)f  the  attack,  and  before  the  eruption  appears, 
exhibiting  comatose  or  convulsive  symptoms,  from  the  over- 
whelming of  tlie  cerebro-spinal  system  with  the  scarlatinous 
poison.  Or  the  eruption  may  partially  appear  and  then  recede 
or  aHsume  a  livid,  hemorrhagic  or  petechial  type,  and  be  followed 
by  albuminuria,  diarrhea,  coma  and  death. 

Either  septic  or  uriwmic  poisoning  may  cause  a  case  of  scarlet 
fever,  which  has  been  running  a  benign  course,  to  suddenly 
assume  a  malignant  type.  The  urtemia  in  such  cases  is  due  to 
the  development  of  scarlatinal  nephritis,  and  the  septic  poison- 
ing is  due  to  a  septic  element  in  the  ichorous  discharges  from 
the  nostrils,  or  to  a  septic  poison  developed  during  the  suppura- 
tive process  which  occurs  when  immense  cervical  abscesses  are 
formed. 

The  general  symptoms  are  of  necessity  more  severe  in  malig- 
nant than  in  ordinary  cases.  The  fever  is  usually  intense,  al- 
though in  hemorrhagic  cases  the  temperature  is  not  always 
specially  high.  There  is  great  restlessness  with  depression  of 
strength,  and  a  decided  tendency  to  delirium  and  stupor;  at  times 
stupor  or  coma  may  alternate  with  convulsions.  The  respirations 
ere  accelerated,  and  the  pulse  ranges  from  140  to  150  or  even  170 
beats  per  minute.  In  most  instances,  especially  if  throat  symp- 
toms are  pronounced,  a  loud  gurgling  noise  is  heard  in  the  throat 
•when  the  patient  is  asleep  or  dozing.  Nausea  and  vomiting  are 
usually  prominent.  In  severest  cases  there  may  be  diarrhea. 
The  face  is  deeply  flushed  and  anxious.  Laryngitis  not  infre- 
quently occurs,  evidenced  by  frequent,  hoarse  or  croupal  cough, 
aphonia  and  dyspncea  with  stridulous  respiration.  Usually 
within  four  or  five  days,  if  no  improvemsnt  takes  place,  the  pa- 
tient lapses  into  a  typhoid  condition  and  dies  in  from  three  to 
ten  days. 


)f  ganprene. 
liiitic  plandH 
occnvH.  In 
:  tlio  glim  J  a 
,t  terraiimtos 
I  and  often 
eafnt'HH,   are 

jrish  shortly 
ion  appears, 
ra  the  over- 
scarlatinous 
then  recede 
1  bo  followed 

ise  of  scarlet 
to  suddenly 
ses  is  due  to 
eptic  poison- 
harges  from 
the  siippura- 
ibscesses  ore 

ere  in  malig- 
r  intense,  al- 
not  always 
epression  of 
per;  at  times 
I  respirations 
0  or  even  170 
throat  symp- 
iu  the  throat 
vomiting  are 
be  diarrhea, 
is  not  infre- 
)upal  cough, 
in.  Usually 
)lace,  the  pa- 
from  three  to 


IP   MEgUKLrt. 


411 


Tho  .lt*^'-i<»n  oi  ^  M  or  malignant  cases  of  scurlot  fovt^r  is 
uncertain  Lite  im^  m-  destroyed  in  a  few  hours  or  tho  patituit 
mayliugf  for  i«>vor»i  days,  sonietiines  for  two,  three  or  even  six 
weeks.  Tlie  uveriige  duration  is  from  eighteen  hours  to  ftve  .)r 
six  days. 

IrreKillaritles.— At  times  the  eru|)ti(m  appears  first  upon  the 
extremities  and  trunk,  and  afterwards  alM)ut  the  neck  and  clavic- 
ular  regions.  It  may  be  either  short  lived  or  unusually  pro- 
longed. Miliary  papules,  minute  vesicles  t)r  purpuric  lesions 
may  appear  upon  the  affected  surface.  Occasionally,  during  the 
prevalence  of  scarlet  fever  epidemics,  the  oidy  local  manifesta- 
tion of  the  disease  is  the  sore  throat,  no  eruption  apiMjaring. 
Such  cases  have  been  termed  ncarlalina  siuv  cmptimf,  and  are 
capable  of  imparting  the  regular  form  of  the  disease  to  others. 
Another  irregularity  consists  in  the  development  of  an  eruption 
without  fever  or  throat  symptoms.  Some  writers,  with  doubtful 
propriety,  make  mention  of  a  Intent  scarlet  fever,  which  is  marked 
by  the  absence  of  throat,  cutaneous  and  febrile  manifestations, 
the  only  evidence  of  the  occurrence  of  the  disease  being  the 
appearance  of  the  characteristic  sequels. 

Occasionally  during  desquamation,  the  skin  of  the  chest  ap- 
pears reddened  and  hypericmic.  Not  uncommonly  during  con- 
valescence a  mottled  rash,  due  to  the  escape  of  coloring  matter 
into  the  surrounding  tissue,  appears  upon  the  legs  and  lasts  only 
a  few  days.  Constitutional  symptoms  seldom  attend  these  rashes. 
Sometimes,  as  late  as  four  weeks  after  the  first  appearance  of 
the  eruption,  in  consequence  of  some  septic  condition,  a  soreness 
of  the  throat  with  injection  of  the  fauces  reappears,  accompanied 
by  albuminuria  and  the  development  of  a  chest  rash,  which  lasts 
from  twelve  hours  to  two  or  three  days. 

Complications  and  Sequels.— The  most  common  sequel  of 
the  disease  is  scarlatinal  dropsy.  It  attacks  mostly  the  sub-cu- 
taneous tissues,  when  it  is  known  as  anasarca.  Not  infrequently 
it  affects  the  serous  cavities  and  the  internal  organs,  and  causes 
oedema  of  the  lungs,  ascites,  hydrothorax,  hydroperioardium  or 
hydrocephalus. 

Anasarca  is  present  in  about  one-fifth  of  all  cases,  and  usually 
occurs  in  the  course  of  the  second  or  third  week  of  the  disease, 
during  the  process  of  desquamation,  or  just  as  desquamation  is 


II' 


&i»^iim^msi&^ii^»ismiim.i»i^^i^''' 


412 


LECTVnW  ox   KKVF.IIH. 


hciiifj;  oomplotod.  It  f»4(l'/»WH  uio<loriito  oftfliicr  tlinii  Hovoro  onHOH, 
nml  \h  produced  l)y  chnn'^cH  in  tlio  kidiu-ys,  niaiidy  iiiducod  hy 
Boine  poculiiirity  in  tlip  scnirlot  U}\vr  poison,  idtlioUf,'li  coinnionly 
l»eliov<'d  to  ho  du(>  to  tl  iiiriuonce  of  cold.  It  first  hIiows  its«'lf 
in  tiio  tnco,  nnd  is  nvm\  mnrivod  xlKiut  tiio  oyclids.  From  tho 
face  it  extinuls  (tvor  tlic  l)ody,  iiiul  if  it  becomi's  gcnerid  is  apt  to 
1)0  atteudod  hy  iiior*'  or  loss  asoitos. 

Troqaontly  for  two  or  throo  days  hofore  the  occurrenco  (tt  the 
aniisarca,  the  pationt  is  rostlosH  and  sloopless,  and  oomplnins  of 
pain  in  the  hoad,  uiiovoxia,  nauBoa  nnd  vomiting.  The  skin  he- 
conios  hot  and  dry,  and  the  toniporaturo  is  raisod  two  or  throo 
do(,'rooH.  The  urino  is  high-eoloroil  and  soanty,  and  if  examined 
will  i)o  found  to  contain  alhuinon  and  exudative  casts. 

In  mild  cases  after  the  anasarca  has  continuod  for  two  or  three 
days  it  begins  to  decline,  the*  gi'neral  synij)tonis  disappear,  and 
the  urine  returns  to  normal.  In  more  severe  cases  it  is  apt  to 
become  extensive  and  may  remain  for  a  week  or  ten  days.  In 
violent  cases  it  steadily  increasos,  ])uflino8s  of  the  face  nnd 
oedema  of  the  limbs  become  more  nnd  more  marked,  the  tem- 
I)eratu''o  steadily  rises,  and  tlio  urinc!  becomes  scanty  or  is  en- 
tirely suppressed.  If  the  disease  is  not  removed,  the  effusion 
may  extend  to  the  serous  cavities  and  internal  organs.  Death 
may  occur  from  coma  sometimes  preceded  by  convulsions,  due 
to  urajmia,  from  asphyxia  occasioned  by  oedema  of  the  lungs  or 
hydrothorax,  or  from  hydrocephalus. 

(Kdcmd  of  the  jjloilis  is  a  dangerous  complication.  It  not  in- 
fro(juently  (w^curs  in  connection  with  exteusive  suppuration  of 
the  glands  nnd  areolar  tissue  about  the  neck.  Abucrsacs  (iboiit 
ihc  Uirodt  are  not  uncommon  in  scrofulous  subjects. 

Diphtheria  is  a  not  very  rare  complication.  It  usually  appears 
suddenly,  and  is  characterized  by  the  i)ath()gnomonic  exudation 
and  attendant  depression  of  the  disease.  It  may  develop  at  any 
period  of  the  fever,  but  generally  occurs  during  desquamation. 
Its  ndA'ont  is  of  serious  import,  as  it  iisnally  terminates  fatally. 

Bronchitis  and  pneumonia  are  rare  complications.  Pleuritia 
is  quite  common. 

Endocarditis  is  the  most  common  inflammation  of  the  serous 
membranes,  occiu'ring  as  a  complication  of  scarlet  fever.  It  is 
usually  idcerative  in  character,  and  may  give  rise  to  either  sep- 
ticaemia or  embolism. 


■HHti 


COMPLICATIONH  AND   SKgUELH. 


413 


m 


^voro  cnHPH, 
iiulucod  hy 

coiiinioiily 
liowrt  itH«'lf 

From  th«' 
n\  in  a|>t  to 

Bnc(>  of  the 
miplniuH  of 
he  skin  be- 
no  or  three 
f  exnmined 

• 

wo  or  three 
ippf  ar,  nnd 
it  ih)  apt  to 
I  days.  In 
!i  face  nnd 
d,  tlie  teui- 
ty  or  is  en- 
lie  effusit)!! 
118.  Death 
ilsious,  due 
lie  luiigB  or 

It  not  in- 

[iiiration  of 
r's.s'f'i!  (ibout 


Pffiiuirditin  may  octnir,  but  it*  not  aw  frequently  observed  as 
is  tMiducurditiH. 

I'rrihniilin  is  ii  rare  complifutioii.  When  it  do«'s  occtir,  it  is 
apt  to  be  Hiib-aeiite. 

lt(i»fi'(>-iiilrsliii(il  <h'fi<>t'<h'rs  are  not  uncommon.  When  w^vero 
or  ionj^  continiii'd,  they  niiiy  prove  danj^eious. 

Cahirrhtil  and  ixirriicliiiitinlinift  lu-phviUx  are  important  and 
justly  dreaded  i-omplicatioiis  (Uuin^  the  sta^je  of  descpiamatioii. 

Iili('iini<ifi»iii,  of  an  inllamniatory  charaeter,  sometimes  occurs 
thiriiij,'  the  th'sciuamative  p(>riod.  It  usually  travels  rapidly  from 
one  joint  to  another,  and  sc^ldoni  lasts  lonj^er  than  f(mr  or  five 
(biys.  Sui>i>ur<ilive  Hiinoritis  is  recordeil  among  the  occasional 
seipiels. 

PliljjrIcniiUir  voiiJiiiiHivitiH  is  the  most  frequent  eye  complica- 
tion. J'droliiHi's  of  the  ciliani  vittsclr  and  loss  of  power  of  ac- 
commodation sometimes  occur  as  a  sequels.  Occasionally  de- 
striidion  of  flir  rovuco  occurs,  as  a  result  of  severe  keratitis. 

Otitis  is  a  not  uncommon  se(piel.  it  may  be  either  external, 
middle  tu*  internal,  and  is  generally  due  to  the  (extension  of  the 
intlanimation  up  the  Eustachian  tube.  Sometimes  it  terminates 
in  ulceration  and  destroys  the  tympanum,  and  even  the  ossicles, 
and  may  induce  caries  of  the  mastoid  process  of  the  temporal 
bone.  It  is  apt  to  be  associated  with  more  or  less  permanent 
deafness,  and  may  prove  fatal  by  the  eventual  production  of 
meningitis  or  even  abscess  of  the  brain. 

Chronic  and  })ui'ulent  numl  catarrh,  which  may  '^sult  in 
caries  of  the  nasal  bones,  is  a  not  uncommon  sequel. 

Chorea  occasionally  appears  during  convalescence. 


lly  appears 
exudation 
elop  at  any 
quamation. 
tea  fatally. 
Pleuritia 


the  serous 
ever.  It  is 
either  sep- 


,  LECTURE  XXIX. 

Scarlet  Fever — (Continued.) 

ANALYSIS   OF   CHART.  . 

The  Nervous  System.-A  chill  or  chilliness  is  an  initial 
sympto^  in  some  cases  of  scarlet  fever.  Frequently,  however, 
it  is  absent  or  but  feebly  marked. 

Headache  occurs  among  the  earlier  symptoms.  It  is  often 
only  moderately  intense,  sometimes  it  is  slight.  Rarely,  it  aug- 
ments  during  the  eruptive  stage.  Generally  it  terminates  upon 
the  advent  of  delirium.  . 

Pains  in  the  back  and  limbs  are  prominent  symptoms  during 
the  early  'lays  of  the  attack.  There  is  frequently  some  tender- 
ness about  the  joints. 

DcUrium,  manifested  by  incoherency,  is  present  m  all  severe 
cases.     Occasionally  in  malignant  cases  delirium  and  coma  usher 
in  the  disease.     Active  delirium,  carphologia  and  subsultus  ten- 
.  dinum,  characterize  severe  cases. 

Resilessness,  iactitation  and  sleeplessness,  are  apt  to  be  more 

or  less  marked.  . 

Drowsiness,  verging  gradually  into  coma,  often  exists  in  severe 

cases  from  the  start.  t*      + 

Great  debiUhj  is  an  early  symptom  in  malignant  cases,     it  not 
infrequently  remains  as  a  sequel  in  other  cases. 

Coma  occurs  in  by  far  the  greatest  number  of  fatal  cases,  and 
is  generally  the  forerunner  of  death.  In  violent  cases  it  fre- 
quently alternates  with  convulsions.  Occasionally  coma  appears 
suddenly  in  consequence  of  embolism  of  one  of  the  cerebral 
vessels,  in  patients  who  before  this  occurrence  appeared  to  be 
doing  well. 
(414) 


^■iiftf^tf'TiT  '»l-|«ftl''»i<i'f"''"™'''T'«'« 


J2->, 


ms.    It  is  often 

Rarely,  it  aug- 

berminates  upon 


mptomB  during 
}ly  some  tender- 

jnt  in  all  severe 
I  and  coma  usher 
id  subsultus  ten- 

e  apt  to  be  more 

n  exists  in  severe 

mt  cases.    It  not 

£  fatal  cases,  and 
ent  cases  it  fre- 
lUy  coma  appears 
)  of  the  cerebral 
:e  appeared  to  be 


I 


4EI6 


LKCTUllKS  ON  FEVERS. 


Convulsions  often  usher  in  the  attack  iu  childreu. 

Paralysis  is  not  of  comuion  occurrence. 

Casos  that  begin  witli  violent  nervous  phenomena,  and  are 
afterwards  characterized  by  the  appearance  of  severe  throat 
symptoiUB,  usually  terminate  fatally. 

The  Temperature.— In  all  cases  of  tolerably  severe  scarlet 
fever  the  temperature  rises  rapidly,  and  may  reach  lOiJ  Fahr. 
or  104"  Fahr.  within  a  few  hours.  It  increases,  as  a  rule,  with 
the  appearance  of  the  evui)tion,  and  remains  between  104 "  Fahr. 
and  10(5'  Fahr.  until  the  rash  begins  to  decline.  At  times  it  is 
hyperpyretic,  and  reaches  107°  Fahr.  or  108 '  Fahr.  on  the  second 
day.  It  runs  high  in  malignant  cases,  and  has  been  known  to 
exceed  112^  Fahr.  in  fatal  cases. 

Defer ci'scence  is  frequently  irregular  and  may  be  delayed  by 
complications.  The  temperature-fall  dates  from  the  decline  of 
the  rash,  and  genei-ally  requires  from  three  to  eight  days  for  its 
completicm.  Exceptionally,  after  a  moderate  exacerbation,  it 
reaches  the  normal  in  twelve  hours.  Occasionally  it  takes  the 
zigzag  descent  of  lysis.  A  sub-normal  temperature  sometimes 
sets  in  before  the  normal  is  rendered  certain.  In  some  cases  the 
temperature  pursues  a  descending  course  while  all  the  severe 
constitutional  symptoms  continue;  the  patient  dies  whilst  the 
temperature  falls  still  lower,  or  undergoes  fatal  perturbations. 
Its  descent  may  be  interrupted  by  renewed  exacerbations,  usually 
traceable  to  some  complications.  In  typhoid  states  it  may  re- 
main high  for  ten  days  or  two  weeks  after  the  fading  of  the  rash. 

During  convalescence  it  rema^js  normal  unless  elevated  by 
complications.  In  fatal  cases,  if  death  occurs  during  the  stage 
of  eruption,  the  temperature  ranges  high  until  death  approaches 
when  it  generally  falls.  If  death  takes  place  during  the  decline 
of  the  eruption,  the  temperature  may  either  rise  or  fall  in  the 
death  agony. 

The  Pulse. — The  frequency  of  the  pulse  is  a  marked  symp- 
tom in  scarlet  fever.  It  frequently  reaches  120  or  140  soon  after 
the  onset  of  the  attack,  and  is  full  and  compressible.  In  severe 
cases  it  may  run  np  to  150,  160  or  even  170.  As  the  disease 
progresses  towards  a  fatal  termination  it  becomes  small  and  very 
rapid,  and  is  often  uncountable. 

The  Respiratory  Systeui. — The  respirations  are  generally 


I! 


-^ 


ena,  and  are 
levere  throat 

evere  scarlet 
1  lOir  Fahr. 
a  rule,  with 
11  104  Falir. 
At  times  it  is 
in  tlio  s(;t'()ml 
eu  known  to 

e  delayed  by 
he  decline  of 
it  days  for  its 
icerbation,  it 
y  it  takes  the 
re  sometimes 
Mue  caseH  the 
,11  the  severe 
ea  whilst  the 
)erturbations. 
tions,  usually 
tes  it  may  re- 
g  of  the  rash, 
elevated  hy- 
ing the  stage 
h  approaches 
g  the  decline 
or  fall  in  the 

arked  symp- 
40  soon  after 
3.  In  severe 
the  disease 
nail  and  very 

re  generally 


THE  THROAT. 


417 


natural,  although  when  the  fever  runs  high  they  are  somen  Imt 
quickened.  A  frequent,  guttural,  dry  cough  is  often  present. 
In  severe  cases  the  respirations  become  accelerated.  As  a  result 
of  the  throat  affection  they  become  labored  and  difficult,  and  are 
l)erformed  with  a  noise  like  that  of  one  strangling.  From  this 
circumstance  is  derived  the  8])anisli  name  for  the  disease,  (/(iro- 
iillo.  The  voice  is  apt  to  be  hoarse,  and  in  severe  cases  may 
become  whispering  or  lost,  in  consequence  of  extensive  exuda- 
tion into  the  larynx. 

The  Throat. — Sometimes  a  feeling  of  roughness  in  the  throat 
with  pain  during  deglutition  is  the  first  intimation  of  the  ap- 
proach of  the  disease  Exceptionally,  in  the  mildest  cases,  there 
may  be  no  pain  in  swallowing,  but  little  redness  over  the  tonsils 
and  soft  palate,  and  no  inilammation  or  swelling  of  the  tliroat. 
In  most  cases,  however,  there  is  more  or  less  swelling  of  the 
tonsils,  and  general  tumefaction  of  the  soft  i)arts  of  the  throat. 
As  the  eruption  progresses,  the  fauces  become  more  swollen,  the 
redness  of  the  mucous  membrane  deepens,  the  tonsils  become 
the  seat  of  more  or  less  intense  parenchymatous  inflammation, 
and  are  frequently  spotted  with  a  white  or  ash-colored  exudation. 
This  exudation  differs  from  that  of  diphtheria  in  adhering  less 
closely,  in  being  ash-colored  instead  of  yellow,  in  appearing  u{)on 
a  uniformly  reddened  mucous  membrane  instead  of  a  simply 
circumscribed  redness,  and  in  not  coming  off  in  dense  membra- 
nous layers.  The  exudative  spots  may  remain  from  one  to  tiiree 
or  four  days,  and  are  then  thrown  oft"  permanently.  Occasionally 
they  form  in  successive  crops.  Hawking  and  spitting  are  apt  to 
be  troublesome  on  account  of  the  collection  of  mucous  in  the 
throat  and  fauces.  Fetor  of  the  breath  is  more  or  less  pro- 
nounced, according  as  the  exudation  is  slight  or  extensive. 

In  severe  cases  the  exudation  may  become  dark  and  offensive, 
and  leave  deep,  ragged,  ashy-looking  \ilcers  on  the  throat  and 
tonsils.  Inflammation,  swelling  and  induration  of  the  lymphatic 
glands  and  cellular  tissues  about  the  angle  of  the  jaw  and  under 
the  chin  are  almost  constant  accompaniments.  The  tumefaction 
may  extend  to  the  sides  of  the  neck  and  throat,  and  gi-eatly  em- 
barrass respiration.  In  such  cases  there  is  great  danger  of  cedema 
of  the  glottis.  Extensive  suppuration  in  the  glands  and  areolar 
tissue  about  the  neck  sometimes  occurs.  Sloughing  pharyngitis 
nc»t  infrequently  occurs  in  the  worst  forms.     In  malignant  at- 


K^^iimm^mii^isi^i!mm^^m^s^!k:mAm,sm^ 


i 


418 


LECTUliKS   ON   ri.VZUS. 


tacks  there  may  be  evidences  of  gangrene  of  the  pharynx  and 
uvula. 

The  Cutaneous  Surface.— The  skin  becomes  hot  and  dry,  .nd 
the  i'nce  Hushed  shortly  before  the  onset  of  the  attack.  The  heat 
i(4  UMually  pungent  in  character,  and  the  integument  is  slightly 
swollen.  An  indescribable  od<ir— likened  by  some  to  that  of  old 
ch(,ege— readily  discernable  when  once  recognized,  often  attaches 
to  the  scarlet  fever  patient,  and  is  an  important  aid  in  diagnosis. 
More  or  less  itching  and  burning  attends  the  cutaneous  conges- 
tion, and  increases  in  intensity  as  the  disease  progresses. 

The  erupiion  appears  on  the  second  day  of  the  fever  and  con- 
stitutes the  characteristic  clinical  phenomenon  of  the  disease. 
It  appears  first  about  the  neck  and  clavicular  regions,  and  ex- 
tends rapidly  over  the  trunk  and  extremities.  It  frequently 
spares  the  face,  and  the  skin  about  the  mouth  is  usually  poUid 
The  first  appearance  is  in  the  form  of  fine  red  dots  or  points. 
These  dots  form  irregular  patches  of  considerable  size,  which 
quickly  coalesce,  and  give  to  the  skin  a  distinctly  scarlet  color. 
In  malignant  cases  the  rash  comes  out  late,  and  is  either  pale 
and  indistinct  or  dark  and  livid.  In  rare  instances  it  is  wholly 
wanting.  In  mild  cases  it  is  frequently  of  short  duration  and 
occurs  only  in  i^atches  which  do  not  coalesce.  It  reaches  its 
height  about  the  fourth  day,  and  then  remains  stationary  for  one 
or  two  days,  after  which  it  begins  to  decline.  It  is  most  vivid 
and  remains  longest  upon  the  back,  loins,  inner  surfaces  of  the 
arms  and  thighs,  and  flexures  of  the  joints.  The  surface  of  the 
eruption  is  usually  smooth;  but  in  some  cases,  particularly 
up(m  the  extensor  surfaces  of  the  extremities,  on  account  of  the 
enlargement  of  the  papillro  it  is  slightly  roughened.  Occasion- 
ally minute  miliary  vesicles  are  scattered  over  the  surface. 

Desquamation  usually  commences  about  the  sixth  day,  first 
u])on  the  neck,  and  then  gradually  extending  over  the  body. 
"Where  the  skin  is  thin,  the  epidermis  comes  off  in  thin,  light 
scales.  Where  it  is  thick,  as  on  the  palms  and  soles,  it  peels  off 
in  large  flakes.  As  the  rash  fades  it  leaves  a  yellowish-brown 
pigmentation  which  gradually  disappears.  In  severe  cases  the 
hair  falls  off,  as  in  all  long  fevers. 

The  Digestive  Tract.— The  tongue  is  at  first  coated  white  or 
yellowish-white  and  is  of  a  deep-red  color  at  the  tip  and  edges. 


I 


-  t 

I 


pharynx  and 

t  and  dry,  .nd 
,ck.  The  heat 
ent  is  slightly 
to  that  of  old 
often  attaches 
1  in  diagnosis, 
neous  conges- 
resses. 

Eever  and  con- 
f  the  disease, 
gions,  and  ex- 
It  frequently 
usually  pnllid 
lots  or  points, 
le  size,  which 
scarlet  color. 
[  is  either  pale 
es  it  is  wholly 
duration  and 
[t  reaches  its 
iouary  for  one 
t  is  most  vivid 
urf aces  of  the 
surface  of  the 
1,  particularly 
iccount  of  the 
3d.  Occasion- 
I  surface. 

ixth  day,  first 
)ver  the  body, 
f  in  thin,  light 
les,  it  peels  off 
sUowish-brown 
veie  cases  the 

soated  white  or 
tip  and  edges. 


THE   UIIINE. 


419 


During  the  eruptive  stnge  the  coating  exfoliates,  and  the  whole 
surface  assuiiieH  a  «leep  red  and  shining  aspect.  The  papilla) 
become  enlarged  and  projecting,  and  cause  the  tongue  to  present 
the  appearance  of  a  rii)e  strawberry.  This  strawberry-like  or 
cat's  tongue  is  usually  present  in  all  well-marked  oases,  and  is 
pathognomonic  of  the  disease.  It  frequently  continues  for  a 
week  or  ten  days  and  then  returns  to  normal.  The  tongue  is  usu- 
ally moist  throughout  the  attack.  In  malijjiiant  and  fatal  cases  it 
becomes  dry,  brown  and  chapped,  and  sordes  collect  upon  the 
lips,  teeth  and  gums.  Thirst  is  usually  urgent,  and  there  is 
complete  anorexia.  Nausea  and  vomiting  occur  in  the  majority 
of  cases,  and  are  more  urgent  during  the  eruptive  stage.  They 
become  violent  and  constant  in  severe  cases.  The  bowels  are 
natural  or  else  slightly  constipated  in  ordinary  cases.  At  times 
a  slight  gastro-intestinal  catarrh  may  be  present.  Colliquativo 
diarrhea  and  intestinal  hemorrhage  occasionally  occur  in  malig- 
nant cases. 

The  Urine.— The  urine  is  commonly  of  a  deeper  color  than 
in  health,  and  contains  plax  scindens  and  a  large  quantity  of 
lateritious  sediment.  It  is  generally  acid  in  reaction,  and  its 
specific  gravity  is  higher  than  normal.  The  quantity  of  urea 
and  chlorides  is  usually  diminished.  Albumen  is  present  in 
over  half  of  the  cases.  Renal  epithelium,  epithelial  or  hyaline 
casts,  and  blood  globules,  are  apt  to  be  more  or  less  abundant  in 
the  sediment. 

In  severe  cases  the  urine  may  be  very  scanty,  or  even  entirely 
suppressed,  and  is  frequently  attended  by  ursemic  symptoms. 
Usually  whatever  urine  is  voided  is  of  a  dark-red  or  blackish- 
brown,  smoky  color.  The  specific  gravity  runs  high— 1025  to 
1040— and  the  amount  of  albumen,  casts  and  blood  globules  is 
large.  After  a  time,  in  favorable  cases,  the  urine  becomes  more 
abundant,  the  sraokiness  and  albumen  disappear  and  the  specific 
gravity  gradually  returns  to  normal.  In  less  fortunate  and  by 
no  means  rare  cases,  the  albumen  remains  constant,  and  the  mi- 
croscope shows  granular  or  epithelial  casts,  and  free  renal  epi- 
thelium. 

The  Special  Senses.— The  eye  and  ear  are  frequently  involved 
and  are  often  the  seat  of  serious  lesions. 

Conjunctivitis  may  occur  at  any  stn"e.     Phlyctenular  inflnm- 


420 


LECTURES  ON  FEVEHS. 


mation  is  a  not  uncommon  sequel.  Marginal  blepharitis  fre- 
reX  exts  and  is  apt  to  become  chronic.  Prunary  keratitis 
Ty  oLsion  perforation  of  the  cornea.  Transitory  bhndres. 
often  accompanies  the  ordinary  symptoms  of  urannia. 

CatLr liS  Eustachian  deafness  and  external  otitis  are  not 
uncommon  when  the  rash  is  well  marked.  Acute  suppurative 
oSmediaisoftener  present  when  the  «-"  ^^  -  le  s 
prominent,   and  when  the  cutaneous  mamfestations  aie  less 

"^Thf  nasal  mucous  membrane  is  frequently  the  seat  of  an  ex- 
corilig  ct".,  which  is  often  associated  with  a  dangerous 
Lino  pharyngitis.  The  discharge  contains  the  elemens  ca- 
pable of  producing  septic  poisoning.  Not  infrequen  ly  it  le^ls 
to  the  formation  of  ulcers,  and  eventually  necrosis  of  the  nasal 

bones. 

Morbid  Anatomy.-The  characteristic  lesion  of  scarle  fever 
is  to  be  found  upon  the  skin  and  mucous  membi;ane  Mostim- 
poi^ant  changes  may  also  be  observed  in  the  blood,  kidneys,  hver, 
Bnleen  and  lymphatic  glands  pf  the  throat.  .    ^i      i  • 

tZ  S/1 -The  morbid  changes  which  take  place  in  the  skin 
are  mainly  those  of  hyperemia  and  slight  exudation,  and  are 
believed  to  be  due  to  the  irritating  nninve  ot  the  plcuc  scmdc^- 
The  hyperemia  is  limited  for  the  most  part  to  the  conum  and 
papillary  layer,    In  the  early  stages  the  corium  presents  signs 
of  mflammatory  oedema  with  enlargement  of  the  papi  1».  and 
the  whole  is  somewhat  thickened.    Later  the  thickening  becomes 
less  marked,  but  local  thickenings  of  the  stratum  lu^dum  and 
nartial  loosening  of  the  stratum  corneum   are  found.     Ihese 
cC  s  --lly  take  place  previous  to  the  separation  of  large 
massfs  by  desquamation.     The  process  of  d-q-mation  may 
last  only  a  few  days,  or  it  may  continue  for  weeks.     It  s  not  a 
rare  thing  for  it  to  recur  a  second  time  on  the  same  surface. 

The  eruption,  which  is  usually  referred  to  as  the  characteristic 
cutaneous  lesion,  consists  of  pin-he.d  sized,  closely  P^^^^f  P^;"*^ 
between  which  the  skin  is  of  a  natural  color.  In  ^ell-^^'^^ked 
.  cases  the  surface  is  swollen  andintensely  <^»^^^'^^^' ^"l^^"'^^^. 
a  generally  reddened  appearance.  The  spots  are  mainly  circular, 
at'times  they  are  elongated,  especially  on  the  forearms  and  I  g  - 
The  color  of  the  eruption  varies  from  pale  red  o  dark  red,  and 
is,  as  a  rule,  proportionate  to  the  intensity  of  the  fever.     It  i» 


taiSMMiaMM«*i>>iMil 


MOnmi)   ANATOMY. 


421 


iepharitis  fre- 
mary  keratiti* 
tory  bliiidresft 
inia. 

otitis  are  not 
te  suppurative 
symptoms  are 
tions  are  less 

3  seat  of  an  ex- 
sh  a  dangerous 
he  elements  ca- 
[juently  it  leads 
sis  of  the  nasal 

of  scarlet  fever 
L-ane.  Most  im- 
d,  kidneys,  liver, 

3lace  in  the  skin 
idation,  and  are 
le  j)?c«;  acindcns. 

the  corium  and 
m  presents  signs 
he  papillae,  and 
ckening  becomes 
bum  lucidum  and 
e  found.  These 
paration  of  large 
squamation  may 
eeks.     It  is  not  a 

same  surface, 
the  characteristic 
sely  placed  points. 
In  well-marked 
isted,  and  presents 
re  mainly  circular; 
forearms  and  legs- 
X  to  dark  red,  and 
E  the  fever.     It  is 


n  result  of  the  congestion  and  inflnnnnntion  of  the  skin,  which 
may  be  i>resuraed  to  be  due  to  the  irritant  pressure  of  the  plax 
scindens. 

Occasionally  the  eruption  is  accompanied  or  followed  by  acne, 
herpes  or  urticaria.  Not  infrequently  in  malignant  cases,  cuta- 
neous hemorrhages  occur,  which  lead  to  the  formation  of  pe- 
techiie  and  extensive  ecchymoses. 

Tlie  blood  undergoes  various  ciiangos,  and  usually  contains 
phix  scindens. 

The  mucous  membrane  of  the  iousils  and  pharynx  is  red  and 
swollen  at  the  onset  of  the  disease.  Soon  the  parts  become  cov- 
ered with  a  tenacious  mucus,  and  small  elevations  appear  upon 
the  reddened  surface.  In  severe  cases  the  secretion  becomes 
abundant  and  the  membrane  appears  dark  and  oedematous,  and 
may  appear  more  or  less  covered  with  ash-colored  patches.  At 
times  the  membrane  becomes  ulcerated  and  softened.  In  ma- 
lignant cases  gangrene  of  the  pharynx  may  occur. 

Inflammation  of  the  parotid  and  sub-maxillary  lymphatic 
glands,  and  of  the  surrounding  cellular  tissue  is  frequently  en- 
countered. It  may  terminate  in  resolution;  not  uncommonly  it 
ends  in  suppuration,  and  may  be  followed  by  extensive  destruc- 
tion of  connective  tissue. 

Purulent  catarrh  of  the  posterior  nares  occurs  in  severe  cases, 
and  gives  rise  to  troublesome  coryza. 

The  eye  lesions  include  conjunctivitis,  purulent  choroiditis, 
retinitis  and  suppurating  ulcers  of  the  cornea.  The  ear  lesions 
are  puriform  and  are  mainly  located  in  the  middle  and  external 
ear. 

The  kidneys  are,  next  to  the  skin  and  mucous  membrane,  oft- 
enest  affected  in  scarlet  fever.  The  mildest  affection  of  these  or- 
gans is  catarrh  of  the  uriniferous  tubules,  a  condition  usually 
marked  by  more  or  less  extensive  epithelial  desquamation.  Oc- 
casionally a  croupous  inflammation  of  the  tubules  is  induced. 
The  morbid  processes  commence  at  the  malpighian  bodies  and 
extend  to  the  uriniferous  tubules.  Cloudy  swelling  of  the  epi- 
thelial cells  characterizes  the  anatomical  changes  during  the  first 
week.  Infiltration  soon  takes  place  around  the  tubules,  which 
become  stuffed  with  these  clouded  and  enlarged  epithelial  cells 
•or  with   granular  matter  resulting  from   their  disintegration. 


f 


422 


LECTURES  ON  FEVEllS. 


Occasionally  fatty  degeneration  of  the  epithelium  occurs.   Some- 
times abscesses  form  in  the  substance  of  the  kidney. 

Mode  rale  caiarrh  of  the  vagina  not  infrequently  occurs. 

Tlie  spleen  is,  as  a  rule,  slightly  enlarged. 

Tlie  liver  changes  are  similar  to  tliose  of  typhus  fever. 

Bronchial  catarrh  is  frequently  present  during  the  early  and 
late  stages  of  the  disease.  Lobular  broncho-pneumonia  some- 
times occurs  in  severe  cases. 

Synovitis  often  occurs  at  the  commencement  of  desquamation, 
and  most  frequently  attacks  the  small  joints.  When  suppurative 
inflammation  of  the  joints  occurs,  death  may  ensue  from  pytemia. 

The  mesentei'ic,  Brimner's  and  Peyer's  glands  are  not  infre- 
quently enlarged  and  injected.  Sometimes  Peyer's  patches 
present  the  "shaven-beard  appearance"  observed  during  the 
first  week  of  typhoid  fever. 

Differential  Diagnosis. — The  positive  ditvg,nosis  of  scarlet 
fever,  though  impossible  during  the  stage  of  invasion,  is  usually 
attended  with  but  little  difficulty  after  the  appearance  of  the 
eruption. 

The  diseases  with  which  it  is  most  liable  to  be  confounded  are 
erythema,  small-pox,  measles,  german  measles,  roseola,  erysipe- 
las and  diphtheria. 

Erythema  is  to  be  distinguished  from  scarlet  fever  by  the 
damask  rose  color  of  the  eruption,  by  the  smaller  size  of  the 
patches,  by  the  absence  of  constitutional  symptoms,  and  by  its 
dhort  duration. 

The  striking  points  of  differential  diagnosis  between  scarlet 
fever  and  measles  and  small-pox  are  presented  in  the  following 
tabular  arrangement: 

SCARLET   FEYEB. 


MEASLES. 

Very  contagious. 

Most  common  in  chil- 
dren. 

Incubation  variable,  from 
7  to  14  days. 

Duration,  12  to  16  days. 

Prodromal  symptoms,  las- 
8itude,8hivering,  sneez- 
ing, harsh  cough.  Kare- 
ly  vomiting. 


Contagious. 

Most  common  in  chil- 
dren. 

Incubation  uncertain,  av- 
erage about  8  days. 

Duration,  2  to  3  weeks. 

Prodromal  symptoms, 
shivering,  nausea,  vom- 
iting, sore  throat.  Con- 
vulsions occasionally  in 
children. 


SMALL-POX. 
Highly  contagious. 
Most  common  in  adults. 

Incubation   constant,  10 

to  13  days. 
Duration,  3  to  5  weeks. 
Prodromal       symptoms, 

marked  chill,  followed 

by  vomiting  and  severe 

lumbar  pains. 


ccurs.   Some- 

f  occurs. 

fever. 

the  early  and 

Lmouia  some- 

[esqunmatioi], 
a  suppurative 
Erom  pyaeiuia. 
are  not  infre- 
yer's  patches 
d  during  the 

sis  of  scarlet 
ion,  is  usually 
larauce  of  the 

)nfounded  are 
ieola,  erysipe- 

fever  by  the 
3r  size  of  the 
ns,  and  by  its 

Jtween  scarlet 
the  following 

lALL-POX. 

contagious, 
(umon  in  adulta^ 

Ion   constant,  10 

lays. 

1.  3  to  5  weeks. 

lal       symptoms, 

;d  chill,  followed 

[uiting  and  severe 

ir  pains. 


MK.\HLE8. 
Eruption  iippears  on  4th 

day. 
Eruption  consists  (/f  pa- 

pulfH    arranged    in    a 

cri'SC'-ntii'.  manner  on  a 

white  ground. 
Eruption  appears  first  on 

forehead  and  face,  and 

extends     gradually 

downwards. 
Eruption  lasts    ahout  ."> 

days. 
Bkin  has  no  peculiar  odor. 

Bronchitis    and     coryza 

very  constant. 
Sore  throat  rare. 

Dark  red,  irregular  spots 
on  the  palate. 

White  coated  tongue. 


DIFI'EHENTl.VL   DI.VGNDSIS. 


123 


Temperature,      103°     to 

107°. 
Fever  rather  increased  hy 

the  eruption. 
Secondary  fever   ahsent. 

Pulse,  100  to  120  or  160 

Cerebral  symptoms  very 
rare,  and  not  severe. 

Desquamation  slight  and 

branny, 
Catarrhal    pneumonia   a 

frequent  complication. 

Sequels;  chronic  bronchi- 
tis, phthisis  and  chron- 
ic conjunctivitis. 

Vaccination  aflfords  no 
protection. 


HCAULET     I'EVElt. 
Eruption  appears  on  tJnd 

day. 
Eruption  consistsofcioNC- 

ly  packed,  minute  red 

jioiiits,  on  a  brinlit-reil 

liypencniic  uround. 
Eruption  appears  lij-st  on 

chest    and    neck,    and 

spreads  rapidly. 

Eruption   lasts   about    7 

days. 
Skin  has  an  "  old  cheese  " 

odor. 
Uronchitis    and     coryza 

rare. 
Considerable  sore  throat. 

Marked  iiyection  of  the 
fauces.  Tonsils  en- 
larged and  painful. 

Strawberry  tongue. 

Temperature,      105°     to 

112°. 
Fever  not  relieved  by  the 

eruption. 
Secondary  fever  absent. 

Pulse,  100  to  120,  140  or 
170. 

Cerebral  symptoms  fre- 
quent and  grave. 


Desquamation  copious 

and  in  flakes. 
Pneumonia  a  rare  com- 
plication.    Pleurisy 
frequent. 
Sequels;  dropsy,  conjunc- 
tivitis,    deafness    and 
glandular  enlargement- 
Vaccination    aflfords    no 
protection. 


s.MAM.-rox. 

Erujition  apiK'uis  "u  lirrl 
day. 

Er\iption  consists,  lirstof 
papules,  then  of  vesi- 
cles, and  on  tiiu  eighth 
day  c)f  pustules. 

Erujition  appears  llrst  up- 
on the  forehead  and 
al>out  the  moutli. 

Eruption  lasts  from  !)  to 

12  days. 
Skin  emits  a  sickly  odor. 

nronchitis    and     coryza 

rare. 
Slight  sore  throat  and  dry 

cough. 
Eruption    seen    on    the 

back  of  the  pharynx. 

Furred  tongue  with  red 

"dges. 
Temperature,      104°      to 

106°. 
Fever  greatly  relieved  by 

the  eruption. 
Secondary  fever    always 

present. 
Pulse,  100  to  120  or  140. 

Cerebral  symptoms,  espe- 
cially convulsions  in 
children,  frequent. 

Desquamation  in  scabs, 
crusts  and  thick  scales. 

Pneumonia  an  infrequent 
complication. 


Sequels;  glandular  en- 
largements, chronic 
diarrhea,  and  diseases 
of  the  eye. 

Vaccination  protects. 


rs' 


Bfii 


.# 


424 


LECTUUE8  OK   FEVKllS. 


Ifosrohi  differs  from  ncarlot  fovor  in  tlio  Mzo  of  its  papules, 
whic'li  1110  liir^'(n-  and  iiioro  riiisotl  tlian  the  rod  points  of  tlio 
latter  disease.  Tiie  intervening  skin  between  the  points  soon 
becomes  injt^cted  in  scsarlet  fever,  while  in  roseola  it  usually  re- 
mains natural.     Roseola  is  not,  scarlet  fever  is,  contagio.is. 

The  distinctive  symptoms  of  scarlcf  fiver  and  (jcrnKtn  measles 
are  arranged  in  tabular  form  upon  page  402. 

EriiHipeUiH  can  hardly  be  mistaken  for  scarlet  fever,  if  it  is 
remembered  tiiat  the  redness  gradually  extends  from  one  point, 
appears  smooth  and  shining,  and  is  usually  accomi  anied  by 
marked  redema  of  the  connective  tissue. 

Diphiherin  is  distinj^uished  from  scarlet  fever  by  the  usiial 
absence  of  the  eruption,  the  brick-dust-like  flush  of  the  throat, 
and  the  strawberry  tongue.  The  exudation  which  occurs  upon 
the  tonsils  and  pharynx  in  diphtheria,  is  txsually  of  a  dirty  gray 
or  yellowish  color,  resembling  wetted  chamois  leather,  while  that 
which  takes  place  in  scarlet  fever  is  generally  whitish  or  ash- 
colored.  The  urine  in  diphtheria  thongh  frequently  albuminous, 
as  in  scarlet  fever,  never  contains  plax  scindens. 

Prognosis. — The  prognosis  in  scarlet  fever  is  always  uncer- 
tain at  least,  until  after  the  first  twenty-four  hours  of  the  erup- 
tion. It  is  largely  influenced  by  the  type  of  the  prevailing  epi- 
demic, the  character  of  the  attack,  the  vigor  and  age  of  the 
patient,  and  the  presence  or  absence  of  serious  complications. 

F.ivorable  symptoms  are:  a  fully  and  regularly  developed 
rash  of  a  bright  red  color,  mild  cerebral  and  throat  symptoms, 
a  pulse  not  exceeding  one  hundred  and  twenty  beats  per  minute, 
and  a  temperature  below  104°  Fahr, 

Unfavorable  symptoms  are:  early  convulsive  symptoms,  pro- 
longed delirium  or  coma,  persistent  and  long  continued  vomit- 
ing, colliquative  diarrhea,  a  badly-developed  and  dark-colored  or 
hemorrhagic  eruption,  early  and  ulcerative  throat  lesions,  severe 
scarlatinal  coryza,  a  very  rapid  pulse,  a  temperature  above  105° 
Fahr.,  a  dry,  brown  tongue,  a  disposition  to  a  typhoid  state,  and 
the  occurrence  of  any  of  the  more  serious  complications. 

The  rate  of  mortality,  which  is  inversely  proportionate  to 
the  age  of  the  patient,  varies  from  five  to  twenty  per  cent 


[  its  pnpulefl, 
pointB  oi  tlio 

e  points  stKJii 
it  usually  ro- 

itn^ioiis. 

rnian  mcaalca 


fover,  if  it  is 
•oin  one  point, 
jomianied  by 

by  the  usiinl 
of  the  throat, 
h  occurs  ui)on 
)f  a  dirty  gray 
her,  while  that 
hitisli  or  ash- 
[y  albuminous, 

always  uncer- 
rs  of  the  erup- 
prevailing  epi- 
ind  age  of  the 
implications, 
vrly  developed 
•oat  symptoms, 
its  per  minute, 

lymptoms,  pro- 
ntinued  vomit- 
iark-colored  or 
lesions,  severe 
ure  above  105° 
hoid  state,  and 
ications. 
roportionate  to 
per  cent. 


LECTURE  XXX. 
Scarlet  Fever. -(Continued.) 

Treatment. 

Prowhylaxis.- Whenever  scarlet  fever  appears  in  a  fnmily, 

the  paUent  should  be  ^^^^y^ff'^'^^^'^'Z 
if  possible.     The  apartnumt  should  be  large,  wel    h«»>te  1.  "'»] 
l^ZMcd,  and\he  temperature  should  be  mamtau.ed  « t  ,.  > 
to 70°.     Carpets,  hangings,  and  all  un3u,ce.sary  ar  xclos  of  f mn^ 
ture  should  be  removed  from  the  room.     Sheets  sluHild  be  hung 
up  "the  door  and  window  ways,  and  kept  onstanUy  saturated 
ith  Platfs  chlorides  or  some  ^^i«">ff  «*">8  ^•^*"*7-  Jj\l,f„ 
md  body  linen  should  be  changed  daily,  and  immediately  dism- 
JocteTor  baked.     The  discharges  from  the  bowels  and  kidneys 
should  be  received  into  vessels    charged  with    ^l-^"  ectan ts 
S^  chlorides  should  be  sprinkled  on  the  bed  and  about  h^ 
room     Inunctions  with  mildly  carb<.hzed  vaseline      racticed 

ral  timesdaily,  by  preventing  the  disseminatioi^^^^^^ 
Darticles  of  the  epidermis  during  desquamation,  exert  a  maiked 
pro^^^^^^^^^^^  influence.  Nurses,  and  attendants  upon  the  sick 
should  not  mingle  with  the  healthy  members  o  the  family  until 
desquamation  is  completed.  Physicians  should  take  a  long  ride 
tX  open  air  after  leaving  the  sick-room  of  a  scarlatinous  pa- 
tLZ  before  visiting  in  houses  where  there  are  unprotected 

''ItTrecovery  or  death,  the  apartment  should  be  thoroughly 

*  All  cases  of  scarlet  fever  occurring  in  the  county,  must  be  reported  to  the 
county  Clerk;  or,  in  cities,  to  the  City  Board  of  Health. 

(425) 


t 


42U 


LECTUllKS  ON   FKYEIIS. 


tliHinfccU'd  by  tho  Imrniii^'  of  Hiilpliur,  or  l»y  pouring  rrndo  piir- 
\mA\c  lU'id  on  cliloi'idt'  of  liiiio,  or  by  |iliu'iiij»  ozouiziiKj  jyoirtlrrs 
-  foiiipoHcd  of  «Mpiid  jmrtsof  oxalic  acid,  pcroxiihi  of  maii^^aiicHo 
and  poluHHiuiii  pcriuan^iinatc — moistened  witii  water,  in  dinlicH 
tlirou^diout  tiio  room.  Tiio  bed  and  body  linen,  and  all  blankuin 
and  ilannels  that  have  Ihmmi  about  the  IxmI,  hIiou1(1  be  immernod 
in  honii!  diKinfccting  Holution  and  then  thorouf^hly  boih>d  or 
baked.  'J'he  mattraHH,  pilloWH  and  ciiitainH,  and  tho  clothing 
worn  by  nnrH<>H,  Hhoxild  be  expoHcd  to  a  hiji;li  temperature  (240° 
or  250  ),  and  afterward"  well  aired  liefore  beinj^  UHcd.  After 
everytliiu}^  has  been  diHinfectod,  the  woodwtirk  of  the  room 
hlxmld  be  thoroughly  cleaned  with  carboli/cd  water,  tho  walls 
Avhitewawhed,  and  the  apartment  freely  aired  for  at  least  two  or 
three  days. 

It  \H  believed  thnihclldiloinid,  adnnniHterod  morning  and  even- 
ing, will  either  prevent  the  diHoaBe,  or  cause  it  to  run  a  milder 
course.  The  sulpho-carboUilc  of  soda  is  also  recommendeil  for 
the  same  purpose. 

Principal  Keniedies. — The  remedies  ofteneat  indicated  in  the 
preimmitoi'ii  stdyc  are:  aconite  and  belladonna  in  mild  cases; 
veratrum  viride,  belladonna,  solanum,  apis,  ailanthus,  arum,  am- 
monium carb.  and  rhus  in  severe  cases;  and  arsenicum,  ailan- 
thus, lachesis,  amracmium  carb.  and  cami)hor  in  malignant  cases. 

During  the  erupt  ire  nt<i<jc  tho  main  remedies  are:  belladonna 
and  rhu3  in  mild  cases;  apis,  solanum,  mere,  bi-jod,  rhus  tox., 
arsenicum  iodide,  ailanthus,  hyoscyamus,  veratrum  viride  and 
bryonia  in  severe  cases;  and  arsenicum,  ammonium  carb.,  la- 
chesis and  ailanthus  in  malignant  cases. 

In  the  desqnamciiivc  stage  the  principal  remedies  are:  sul- 
phur, arsenicum  and  kali  sulph.  in  mild  cases;  and  sulphur, 
hepar  sulph.,  iielleborus,  squills,  terebinthina,  rhus,  asclepias 
syr.,  apis,  arsenicum,  baryta  carb..  calcarea  carb.,  kali  bich.,  sili- 
cea  and  arum,  in  severe  cases. 

Belladonna  is  the  principal  remedy  in  the  simpler  forms  of 
the  fever,  especially  when  the  eruption  is  smooth,  and  is  accom- 
panied by  pain  in  the  head  and  soreness  of  the  throat.  It  is 
usually  given  in  alternation  with  aconite,  gelsemium  or  veratrum 
viride.  Solanum  may  be  used  instead  of  belladonna  when  the 
spots  are  large,  red  and  livid,  and  when  there  is  a  tendency  to 
convulsions,  esiiecially  in  teething  children.     Veratrum  viride 


ij^u^^t^^t'^tK.MMimiMK^^fVMrm 


FiiiNcli'Ai.  iii:Mi:i)ii:H. 


iU7 


iiiK  cniilt"  <')ir- 
\i:in!f  jininli'i's 

<if  lllllU^'llll(>H<<l 
hitt'r,  in  (linlitH 
li<l  all  hiaiilitits 
it  l)o  iiiiiii(!txo(l 
1^,'lily  Ixiiiod  or 
tlio  clothing 
IHTutuio  (240' 
K  UB«'(l.  Atlor 
k  of  tiio  room 
liter,  tlio  wuIIh 
lit  If'iiKt  two  or 

riling  and  cvcsn- 
to  run  a  milder 
CDinmeiided  for 

indicated  in  the 
in  mild  cases; 
thus,  arum,  am- 
rsenicum,  ailan- 
nalignant  cases, 
are:  belladoniiu 
i-jod,  rhus  tox., 
Tura  viride  and 
inium  carb.,  la- 

tuedies  are:  sul- 

3;  and  Bulphiir, 

rhus,  asclepias 

,  kali  bicli.,  sili- 

mpler  forms  of 
1,  and  is  accom- 
e  throat.  It  is 
um  or  veratrum 
lonna  when  tlie 
is  a  tendency  to 
'crairnm  viride 


is  called  for  when  the  fnver  is  int«'iiH«s  tlio  pulse  very  i'aj)id,  mid 
then*  is  great  dangt'r  of  n'i«'l)Uil  congt'stion.  Uruotiin  i.s  indi- 
cat<'«l  if  the  fever  sets  in  with  an  adyiiiiiiiic  type,  and  (>H|M>ciiilly 
if,  in  conwiMiuence  of  i'xposurn  to  the  fresh  air,  the  eruption  re- 
cedes after  it  is  fairly  out. 

Apin  will  be  of  service  when  there  is  rapid  swelling  of  the 
throat  with  sharp  stinging  (lains,  when  the  rush  is  interspei'sed 
with  n  miliary  eruption,  when  with  su])pi'eHHion  of  eruption 
there  is  entire  supprevHion  ot  urine,  or  when  dropsy  sets  in  with 
swelling  of  the  genitals.  .i't//fn(//if(.s  isnndispensable  when  the 
eruption  assumes  a  livid  hue,  when  the  fever  is  intense  and  the 
heat  pungent,  and  when  there  is  a  fietid  discharge  from  the  nos- 
trils accompanied  by  cracking  at  the  corners  of  the  mouth.  It 
is  adapted  to  malignant  cases,  and  such  as  show  extreme  torpor. 
Arum  is  specially  valuable  in  scivere  eanes  when  the  nose  and 
mouth  are  sore,  when  the  discharge  from  the  nose  is  acrid  and 
excortiating,  when  the  lips  commence  to  swell,  and  when  the 
patient  begins  to  pick  the  iiJigers  and  lips.  Arsrnicnm  iodide 
should  be  thought  of  when  the  discharges  are  irritating  and 
corrosive,  and  there  is  swelling  of  the  lymphatic  glands,  espe- 
cially in  scrofulous  individuals.  Arsrnicum  alb.  is  usoful  in 
malignant  cases,  when  there  is  a  tendency  to  prostration  t)f  the 
vital  powers.  Ammonium  v.(irb.  may  be  needed  when  the  erup- 
tion is  faintly  developed,  when  the  tonsils  are  enlarged,  livid, 
and  more  or  less  covered  Avith  an  offensive,  sticky  exudation,  and 
when  the  parotid  gland,  especially  the  right,  is  inflamed  and 
swollen.  Rhus  iox.  may  be  administered  early,  instead  of  bry- 
onia,  when  torpor  threatens,  the  glands  become  swollen,  the  are- 
olar tissue  becomes  implicated,  rheumatic  pains  appear,  and 
petechitB  are  formed.  lied  iodide  of  mercury  is  always  indicated 
for  ulceration  with  swelling  of  the  glands  of  the  throat,  and  for 
swelling  and  inflammation  of  the  cervical  glands.  Lachcsis  is  a 
remedy  of  the  first  imiK)rtance  when  malignant  throat  symptoms 
appear,  or  when,  duiing  the  decline  of  the  eruption,  the  disease 
assumes  a  typhoid  tendency.  Hepar  sulph.  is  especially  valua- 
ble when  suppuration  threatens. 

Delirium  is  generally  met  by  either  belladatma,  hyosctfomus 
or  siramonium.  Extreme  restlessness  and  irritability  cull  for 
coffea.  Marked  sopor  with  loud,  slow  respiration,  indicates 
opium.    When  the  eruption  is  suppressed  or  recedes,  either 


M 


f.t 


'if'f'<i^mmim>m^&4f.s>'.B^t4ii^a»Mmmeiei:s?^tex. 


'i^a&jmimtmpiii 


428 


LECTUKE8  ON  FEVEBS. 


\ 


apis,  hryonia,  ailanthns,  ipecac,  cuprum  or  opium  will  be  needed. 
Convulsions  before  the  appearance  of  the  eruption  are  met  by 
belladonna,  monotropa,  cuprum,  htjoscyamus  and  vcratruri  vi- 
rida.  Convulsions  during  the  stage  of  desquamation  call  for 
moschus,  veratrum  viride  or  cuprum.  Cases  that  take  on  a  ty- 
phoid tendency  are  usually  met  by  nmica,  hapUsia  or  rhus. 
WJieu  diphtheria  sets  in,  kali  bich.  and  the  red  iodide  of  mercury 
do  excellent  service. 

Tartar  emef.  or  kali  hick  may  prove  serviceable  when  the 
larynx  and  trachea  are  involved,  and  there  is  great  difficulty  in 
breathing.  Ipecac  should  be  thought  of  if  the  chest  is  seriously 
aifected,  or  if  nausea  and  vomiting  are  leading  symptoms.  Spon- 
gia  or  bromine  will  be  of  service  for  the  laryngitis.  Tartar 
emct.  for  pericarditis.  Merciirius,  bryonia  or  rlius  for  pleuritis. 
Arnica,  rhus  or  salicylic  acid  for  articular  rheu'natism.  Arsen- 
icum, phosphorus  or  rhus  if  petechiiB  and  ecchymoses  appear. 
Arsenicum  or  veratrum  alb.  for  diarrhea.  Mercurius  cor.  for 
bloody  stools.  Camphor  when  symptoms  of  collapse  occur  in 
malignant  cases. 

Hellebortis  is  the  principal  remedy  for  anasarca,  and  for 
threatened  hydrocephalus.  Apis,  arsenicum,  benzoate  of  lithia, 
cantharis,  digitalis,  helleborm,  asclepias  syr.,  squills  and  iere- 
6m//tiVia  are  oftenest  indicated  in  post-scarlatinal  dropsy.  He- 
par  sulph.  will  exert  a  favorable  influence  upon  the  tendency  to 
dropsy  if  given  as  soon  as  there  are  traces  of  aVoumen  in  the 
urine. 

Muriatic  acid  or  aurum  mur.  will  he  needed  when  the  nose  is 
sore  and  bleeds  frequently.  Rhus  or  mercurius  nit.  for  phlyc- 
tenular conjunctivitis,  suppurative  choroiditis  or  panophthalmi- 
tis. Gelsemium  for  serous  chorc)iditis.  Aurum  or  kali  jod.  for 
plastic  choroiditis.  Mercurius  cor.  or  arsenicum  for  ulcerative 
changes.  Mercurius  cor.  or  plumbum  for  albuminuric  retinitis, 
Calcarea  carL,  carbo  veg.  or  tellurium  in  external  otitis.  Psor- 
icum  when  there  is  a  thin  fcetid  discharge  from  the  meatus. 
Terebinihina,  hepar,  silicea,  nitric  acid,  aurum  mur.  or  calcarea 
phos.  in  suppurative  inflammation  of  the  middle  ear.  Elaps  in 
<5hronic  suppuration  of  the  middle  ear  accompanied  with  naso- 
pharyngeal catarrh.  Muriatii,  acid  or  silicea  for  otorrhoea  and 
deafness. 

Sulphur,  arsenicum  or  kali  sulph.  maybe  administered  during 


|»i^l^^flilil^ 


MMitiMiiMiM 


I 


LEADING   INDICATIONS. 


420 


'ill  be  needed, 
on  are  met  by 
[  vcratrur.i  vi- 
ation  call  for 
;  take  on  a  ty- 
Hsia  or  rhus. 
de  of  mercury 

ble  when  the 
it  difficulty  in 

V 

st  is  seriously 
ptoms.  Spon- 
jitis.  Tartar 
}  for  pleuritis. 
;ism.  Arsen- 
aoses  appear. 
irius  cor.  for 
apse  occur  in 

irca,  and  for 
oatc  of  lithia, 
lills  and  iere- 
dropsy.  He- 
le  tendency  to 
bumen  in  the 

en  the  nose  is 
nit  for  phlyc- 
lanophthalmi- 
•  kali  jod.  for 
for  ulcerative 
uric  retinitis, 
otitis.  Psor- 
the  meatus, 
r.  or  calcarea 
fir.  Elaps  in 
ed  with  naso- 
itorrhcea  and 

stered  during 


the  stago  of  desquamation  to  hasten  the  process  and  prevent 
sequels.  Baryta,  sulphur  or  iodide  of  calcarea  should  be  thought 
of  when  induration  of  the  cervical  glands  remains  as  a  sequel. 
Leading  Indications.-The  guiding  symptoms  for  the  differ- 
ent  remedies  may  be  compiled  as  follows: 

Aconite.—Great  dry  heat  and  congestion  of  the  skin.  Fine 
prickling,  as  from  needles,  here  and  there.  Eapid  and  full  pulse 
with  great  restlessness  and  hurried  respiration.  Pain  in  tiie 
stomach  with  nausea  and  vomiting.  Fear  of  being  left  alone 
Anxious,  frightened  expression  of  the  face.  Bedness  of  the  soft 
palate  and  uvula  {bell ).     In  plethoric  persons. 

Ailanthus.-General  prostration,  marked  cerebral  symptoms. 
Constant  muttering  delirium  with  sleeplessness  and  restlessness 
(hvos.).  Intolerance  of  light.  Hot,  dry,  harsh  skin.  Violent 
vomiting,  with  dry,  parched  tongue  (ars.).  The  teeth  are  cov- 
ered with  sordes  {bapl,  hyos.).  Livid  eruption,  more  profuse 
on  the  forehead  and  face.  Small,  weak,  rapid  pulse.  Conges- 
tion of  the  throat,  the  mucous  membrane  is  dark  colored,  almost 
livid  Angry-looking  ulcers  in  the  throat,  with  fetid  discharge. 
The  glands  of  the  neck  are  swollen  and  sensitive.  Thin,  watery,, 
offensive  diarrhea.    Petechiae.     In  malignant  cases. 

Ammoninm  carb.-Burning  in  the  throat,  down  to  the  cbso. 
phagus  (canih. ).  Putrid  sore  throat;  gangrenous  ulceration  on 
L  tonsils  {mur.  acid).  Hard  swelling  of  the  right  parotid  and 
cervical  lymphatic  glands.  Tonsils  enlarged  and  livid,  and  cov- 
ered  with  a  sticky,  offensive  exudation.  Faintly  developed  erup- 
tion Stertorous  breathing;  threatened  paralysis  of  the  brain, 
with  excessive  vomiting  (zincum).    Involuntary  evacuations. 

Apis  mel.— High  fever  with  chilliness  from  the  slightest  mo- 
tion Dull  pain  over  the  whole  head  relieved  by  pressure.  So- 
por  with  shrill,  piercing  shrieks.  Great  restlessness  and  nervous 
Station.  Tongue  of  a  deep  red  color  and  covered  with  blisters 
(rhus).  Dryness  of  the  tongue,  mouth  and  throat.  Swelhng 
and  ulceration  of  the  tonsils  and  palate  {mere.).  Stinging, 
smarting  pain  in  the  throat  with  difficulty  in  swal  owing.  Burn- 
ing,  pricking,  smarting,  itching  sensations  in  the  skin  Intensely 
deep  red  rash  {bell).  Great  soreness  in  the  pit  of  the  stomach 
when  touched  {bry.).    Frequent,  foul,  involuntary,  slimy  and 


! 
If 


LECTURES   ON  FEVERS. 

bloody  stools.  Dyspnoea  with  great  restlessness  and  trembling 
{avs. ).  Suppression  of  urine  {hyos.,  opium);  albuminuria  {2)hos. 
acid).    Dropsical  symi)toms  during  desquamation. 

Arsenicum.— Suppression  or  delay  of  the  eruption  \.ith  ap- 
pearance of  petechiiX).  Great  restlessness  and  extreme  prostra- 
tion. Vomiting  and  diarrhea.  Dryness  in  the  mouth  with  thirst 
for  frequent  sips  of  water  ( hell,  opp.  bry. ).  Dry,  brown,  cracked 
tongue  (rhus).  Dryness  and  burning  in  the  fauces  and  throat 
(bt'Il,  lack.).  Grinding  of  the  teeth  while  asleep  (/leM.).  Par- 
oxysmal pains  in  the  ears;  i)rofuse,  thin,  acrid  discharge  from 
the  middle  ear.  Difficult  breathing  with  great  anguish.  Urine 
dark  colored  and  bloody,  and  passed  with  difficulty.  Involun- 
tary micturition  (hyos.)  Pulse  frequent,  hard  and  tense,  or 
small,  trembling  and  intermittent.  Puffiness  of  the  eyelids; 
oedematous  swelling  of  the  feet.    Typhoid  symptoms. 

Arum. — Ichorous  discharge  'from  the  nose,  excoriating  the 
nostrils  and  upper  lip  {ars.  iod.,  mere.  cor.).  Soreness  and 
ulceration  of  the  mouth  and  fauces.  Tongue  red  and  sore  with 
elevated  par;  i'«3.  Swelling  of  the  sub-maxillary  glands.  Scar- 
let eruptiot  >'  )  T  the  body,  with  much  itching  and  restless- 
ness. Picki  ,  t  he  nose,  lips  and  finger-nails.  Spasmodic 
night  cough  ^^  nyos. ) 

Aiirum  iiiur.— Obstinate  foetid  otorrhoea.  Foetid  mucus  dis- 
charge from  the  nose.  Caries  of  the  nasal  bones  {calc.  curb.)- 
Painful  swelling  of  the  sub-maxillary  glands. 

Uaptisia. — Great  prostration  with  nervous  restlessness,  espe- 
cially at  night.  Dull,  stupefying  headache  (gels.).  Nausea 
followed  by  vomiting.  The  eruption  is  more  marked  in  the 
tJiroat  than  upon  the  skin.  Dark,  putrid  ulcers  in  the  throat 
with  difficult  deglutition.  Swelling  of  the  parotid  glands.  Pu- 
trid, offensive  breath  with  profuse  salivation  (mere).  Tongue 
covered  with  a  yellowish-brown  coating  in  the  center,  but  red 
and  shining  at  the  edges.     Typhoid  symptoms. 

Baryta  carb. — Right  parotid  swollen  and  painful.  Inflam- 
mation of  the  tonsils  with  tendency  to  suppuration  (hepar). 
Clironic  induration  of  the  tonsils  {calc.  carb.).  Swelling  of  the 
sub-maxillary  glands  (were).  Ailments  during  and  after  des- 
quamation.    Adapted  to  scrofulous  children. 


if 


it 


LEADING   INDICATIUXS, 


431 


Ind  trembling 
liimria  (2)/ios. 

tion  \,  ith  ap- 

■eme  prostra- 

ith  with  thirst 

•own,  cracked 

IS  and  throat 

(hell.).    Par- 

scharge  from 

;uiBh.    Urine 

ty.     Involun- 

and  tense,  or 

the   eyelids; 

>ms. 

coriating  the 
Soreness  and 
and  sore  with 
jlands.  Scar- 
;  and  restless- 
3.    Spasmodic 

tid  mucus  dis- 
i  {calc.  curb.). 

essness,  espe- 
'Is. ).  Nausea 
larked  in  the 
in  the  throat 
glands.  Pu- 
'c. ).  Tongue 
nter,  but  red 

ful.  Inflam- 
ion  (hepar). 
celling  of  the 
md  after  des- 


Belladoiina. — High  fever  and  sore  throat.  Severe  head  symp- 
toms with  delirium.  The  head  is  hotter  than  other  parts  of  the 
body  {am.).  Drowsiness  broken  by  starts  and  frightened  out- 
cries. Convulsive  motions  of  the  limbs.  Smooth,  scarlet-red 
eruption  upon  the  skin.  The  skin  is  so  hot  that  it  imparts  a 
burning  sensation  to  the  hand.  Great  dryness  of  the  fauces  and 
throat.  Inflammation  of  the  fauces  and  pharynx,  with  dark 
redness  of  the  mucous  membrane,  and  burning,  stinging  pains 
{(ijiis).  Face  fiery  red,  or  else  pale,  puffy  and  sunken.  Tongue 
white  in  the  center  with  red  edges  (gels.),  or  red  all  over  with 
raised  papilla).  Difficult  deglutition;  fluids  swallowed  return 
through  the  nose  {kali  bich.).  Stomach  and  abdomen  sensitive 
to  the  touch  {bry.).  Swelling  of  the  neck,  extremely  painful  to 
the  touch  and  motion. 

Bromine. — Swelling  and  induration  of  the  sub-maxillary  and 
left  parotid  glands  {eoniwrn).    Diphtheritic  complications. 

Bryonia. — Exceedingly  irritable,  everything  makes  him  angry 
{cham.).  Sensation  as  if  sinking  deep  down  in  bed.  Headachy 
as  if  everything  would  press  out  of  the  forehead,  worse  on  mo^ 
tion  {bell.).  Stitches  in  the  throat  when  swallowing  {bell.). 
Dry,  parched  lips.  Delay  or  sudden  retrocession  of  the  erup- 
tion {ipecac).  Sensation  of  weight  upon  the  chest  with  trouble- 
some cough.  Symptoms  of  pleuritis  or  meningitis  {hell.).  Drop- 
sical symptoms.     Constipation. 

Oalcarea  carb.— Sore  throat  with  difficult  deglutition.  Swell- 
ing and  induration  of  the  glands  of  the  neck  {baryta,  mere). 
Aphthte  on  the  tonsils  and  roof  of  the  mouth.  Accumulation  of 
mucus  in  the  air  passages.  Purulent  discharge  from  the  ears 
{hepar,  mere).  Swelling  and  redness  of  the  lids,  with  nightly 
agglutination  (stti!pA.).  Ulceration  of  the  nostrils.  In  scrofu- 
lous subjects. 

Cam plior.-— Sudden  retrocession  of  eruption  with  coldness  of 
the  skin,  and  great  prostration  {cuprum).  Suffocative  dyspnoea. 
Accumulation  of  mucus  in  the  air  passages  {ipecac).  Great 
precordial  anxiety.  Weak,  scarcely  perceptible  pulse  {carbo 
veg. ).     Cold,  clammy  sweat  {verut  alb. ).    Suppression  of  ui-ine. 

Capsicum. — Burning  and  smarting  in  the  tliroat,  worse  be- 
tween the  acts  of  deglutition.  Burning  vesicles  on  the  tongue 
and  mouth.     Shivering  and  chilliness  after  drinking   {ars.). 


% 


^ 
[ 


LECTUnES  ON  FEVEB8. 


Painful  swelling  behind  the  ear.     Caries  of  the  mastoid  pro- 
cess.    Exalted  sensibility  of  nil  the  senses  {coffea). 

(.'arbolic  acid.— Dusky  red  face,  with  a  white  circle  around 
the  mouth.  Lips  and  tongue  dry  and  covered  with  sordes. 
Fauces  fiery  red  and  swollen.  Ulcerated  patches  on  the  lips  an  I 
cheeks.  Extremely  foetid  breath  {bopl).  Liquids  on  being 
swallowed  return  through  the  nose.  "Weak  or  thready  pulse. 
ExcessiA  e  prostration  with  dizziness  and  lieadache.  Eruption  of 
a  dark  red  color.  Miliary  vesicles  all  over  the  body.  Urine 
light-colored  and  scanty.  Involuntary  discharge  of  mucus  from 
the  anus  when  urinating. 

Carbo  veg.-  Restlessness  and  anxiety.  Coldness  of  the  breath 
and  tongue  (rcral  alb.).  Excessive  prostration  {ars.).  Liter- 
nal  burning,  wants  to  be  fanned  (nrs.).  Sticky,  cold  perspira- 
tion. Livid,  purple  appearance  of  eruption  {Inch.}.  Thread- 
like, scarcely  perceptible  pulse.   Putrid  sore  throat.   Ecchymoses. 

Colchicuiii.— Vomiting,  excited  or  renewed  by  every  motion 
(?»•?/.).  Senses  too  acute;  over  affected  by  strong  odors.  (Ede- 
matous swelling  of  the  legs  and  feet  {ars. ).  Scanty  discharge  of 
bloody  urine,  looking  almost  like  ink,  and  containing  albumen- 
Rlieumatic  pains  in  the  arms,  extending  into  the  fingers  (bry.y 
caul.). 

Coiiittlii.— Swelling  and  induration  of  the  parotid  and  sub- 
maxillary glands.     In  scrofulous  individuals. 

Cuprum  acet.— Excessive  nausea;  vomiting  relieved  by  drink- 
ing cold  water  ( bry. ).  Ccnivulsions  precede  the  appearance,  and 
follow  the  sudden  retrocession  of  the  eruption.  Cold,  bluish 
face  with  blue  lips  (lach.).  The  patient  is  afraid  of  every  one; 
clings  tightly  to  the  nurse. 

Digitalis.— Extreme  debility  with  great  anxiety  {aco.). 
Thready,  slow,  intermittent  pulse.  Constant  urging  to  urinate 
with  scanty  discharge.  Dark,  turbid  urine.  Nephritis  after 
desquamation,  with  anasarca  and  oedema  o£  the  lungs. 

Gelsemiuin.— Intense  fever  with  frequent,  soft,  weak  pulse. 
Heat  with  languor  and  drowsiness.  Muttering  delirium  during 
sleep.  Crimson  flush  of  the  face  with  suffused  eyes.  Great 
nervous  excitement.    The  throat  feels  swelled  or  filled  up,  and 


1 


(i 


im 


LEADING  INDICATIONS. 


433 


mastoid  pro- 

circle  aroand 
with  sordes. 
II  the  lips  an  I 
ids  on  being 
hready  pulse. 
Eruption  of 
body.  Urine 
if  mucuB  from 

J  of  the  breath 
ars.).  Inter- 
Bold  perspira- 
;/j.).  Thread- 
Ecchymoses. 

every  motion 
odors.  CEde- 
;y  discharge  of 
ling  albumen- 
fingers  (bry.y 

rotid  and  sub- 


ieved  by  drink- 

ppearance,  and 

Cold,  bluish 

I  of  every  one; 

nxiety  {aco.). 
ging  to  urinate 
Nephritis  after 
ungs. 

ft,  weak  pulse, 
[elirium  during 
i  eyes.  Great 
•r  filled  up,  and 


is  diffusely  red.  Throbbing  in  the  ears,  pains  shoot  from  the 
throat  tt>  the  ears  when  swallowing.  Great  aversion  to  light, 
with  dilatation  of  the  pupils  {bell).  Trembling  and  complete 
loss  of  muscular  power. 

Hellebonis.-Face  pale  and  oedematous.  Urine  scanty  and 
dark  colored;  after  settling  it  looks  like  coffee  grounds.  W  hite, 
gelatinous  stools  with  tenesmus.  Sudden  dropsical  symptoms. 
In  scrofulous  children,  and  in  children  during  dentition. 

Hepar  sulph.-Stitches  in  the  throat  extending  to  the  ear 
(nels.,  kali  bich.);  worse  on  swallowing.  Swelling  of  the  paro- 
tid and  sub-maxillary  glands.  Early  decrease  of  the  urinary 
secretions  with  traces  of  albumen  and  casts.  Discharge  of  fetid 
pus  from  the  ears.     Ulcers  and  specks  on  the  cornea. 

Hyoscyamus.— Late  appearance  of  the  eruption,  causing  great 
nervous  excitement.  Constant  desire  to  get  out  of  bed.  Red, 
sparkling,  staring  eyes  {bell).  Constrictive  sensations  m  the 
throat  with  inability  to  swallow  {bell).  Clean,  parched,  dry 
tongue.  Dark-red,  tlushed  face.  Muscular  twitchings  {stram.). 
Subsultus  tendinum.  Involuntary  evacuations.  Retention  of 
urine  {opium).  Grating  of  the  teeth  {apis,  hell).  Brownish 
spots  or  gangrenous  vesicles  on  the  body. 

Ipecacuanha.— Constant  nausea  and  vomiting  of  green  bilious 
or  slimy  substance.  Suppressed  eruption.  Violent  itching  of 
the  skin.     Dyspnoea. 

Kali  bich.— Throat  purple,  with  small  patches  of  tough,  firmly 
adhering  exudation  all  over  the  fauces.  Pain  extending  to  the 
right  ear,  when  swallowing.  Swelling  of  tiie  parotid  glands. 
Ulceration  of  the  septum  of  the  nose  {aurum).  Purulent  in- 
flammation of  the  whole  nasal  mucous  membrane  {ml  acid). 
Diphtheria. 

Kali  carb.-Inflammation  and  swelling  of  the  right  parotid 
eland  Mouth  and  tongue  covered  with  painful  burning  vesicles 
{mere.  car.).  Smell  from  the  mouth  like  that  of  old  cheese. 
Swelling  between  the  eyebrows  and  upper  lids  like  a  little  bag. 
Kali  permangan.— General  and  excessive  prostration.  Diph- 
theritic exudation  all  over  the  fauces.  Extremely  foetid  breath. 
Great  dyspnoea. 
Lac  caninuni.— Pricking  or  cutting  pains  when  swallowing 


I 


* 

i 


434 


LECTUBES  ON  FEVERS. 


extending  up  to  the  ears.  White  ulcers  on  the  tonsils;  pharyn- 
f^eal  inflammation.  Ulcers  shine  like  silver  gloss.  Enlarged 
glands  in  scrofulous  children. 

Lacliesls.— Great  mental  and  physical  exhaustion.  Aggrava- 
tion of  all  the  symptoms  after  sleep  (apis).  Stupor  and  mut- 
tering delirium  {apis).  The  eruption  appears  slowly,  or  turns 
black  or  bluish.  Dry,  red  or  black,  cracked  and  bleeding  tongue 
(ara.).  Hawking  of  mucus  with  dryness  and  rawness  in  the 
throat.  The  exudation  commences  on  the  left  tonsil  and  spreads 
towards  the  right.  External  swelling  of  the  neck  and  glands. 
External  throat  very  sensitive  to  the  touch.  Black  i^rine ;  watery, 
offensive  stools  (ars.).  Passive  hemorrhages  of  dark,  fluid 
blood.     Typhoid  symptoms. 

Laclinaiitlies.— Heat  and  burning  in  the  skin  with  sensation 
as  if  the  eruption  would  appear.  Circumscribed  redness  of  the 
cheeks  {rhns).  Dryness  and  roughness  of  the  throat,  with 
pricking  pain  when  swallowing.  Stiffness  of  the  neck  after 
scai'let  fever. 

Lithium  benzoate. — In  post-scarlatinal  dropsy,  when  the 
urine  is  dark,  brownish-red,  has  a  pungent  odor,  and  there  are 
present  swelling  of  the  joints,  rheumatic  pains  and  cardiac  symp- 
toms.    Concretions  in  smell  joints. 

Lycopodium. — Inflammation  of  the  throat  of  a  brownish-red 
color,  with  stitches  during  deglutition.  Ulceration  of  the  ton- 
sils, beginning  on  the  right  and  spreading  to  the  left  (opp.  loch. ). 
Swelling  and  suppuration  of  the  tonsils  {hepar).  Swelling  and 
sensitiveness  of  the  sub-maxillary  and  cervical  glands.  Urine 
scanty,  with  or  without  sandy  sediment  Grinding  of  the  teeth 
even  when  fully  awake.  Secondary  eruptions  of  dark-red  blotches 
on  the  hands,  thighs,  back  and  face.  Falling  out  of  the  hair 
{graph.,  phos.). 

Merc,  cyanuret. — Exce8sive  prostration.  Marked  rednesp  of 
the  fauces  with  difficulty  of  swallowing.  Suppression  of  urine 
{apis).  Engorgement  of  the  parotid  and  sub-maxillary  glands. 
Diphtheiitic  symptoms. 

Mercnrius. — Aphthae  in  the  mouth  with  profuse  salivation. 
Ulcers  upon  the  palate  and  tonsils,  with  ash-colored  exudation. 
Dirty-yellow  coating  on  the  tongue.    Swelling  and  inflammation 


•'i 


"^ 


LEADING  INDICATIONS. 


435 


insils;  pharyn- 
OBS.    EnlHi'ged 

ion.  Aggvava- 
tupor  and  mut- 
alowly,  or  turns 
aleeding  tongue 
rawness  in  the 
usil  and  spreads 
eck  and  glands, 
k  irine;  watery, 
of  dark,  fluid 

a.  with  sensation 

i  redness  of  the 

he  throat,  with 

the  neck  after 

opsy,  when  the 
r,  and  there  are 
ad  cardiac  symp- 

f  a  brownish-red 
ation  of  the  ton- 
left  (opp.Zac/t.). 
).  Swelling  and 
L  glands.  Urine 
iing  of  the  teeth 
dark-red  blotches 
g  out  of  the  hair 

[arked  rednesp  of 
pression  of  urine 
maxillary  glands. 

irofuse  salivation, 
solored  exudation, 
and  inflammation 


of  the  glands  of  the  neck.     Foetid  breath  (bap/.  •     ^asa  bones 
Bvol  en  and  sensitive  to  the  touch  {unrum).    Otitis  with  bloody 
offe«B"e  discharge  (grapK  prds.).    Itching  and  restlessness, 
worse  at  night  and  after  sweating. 

Merc.  iod.  flaviis.-Fauces  bluish-red  and  ulcerated  (lacL). 
Indunaion  of  the  parotid  and  cervical  glands  and  tonsils. 
Sma  of  the  neck  and  throat  (apis).  Sharp,  throbbing,  ^r- 
Sg  "ins  in  tbo  leftear.  Tongue  yeUow  with  tip  and  edges  clean 
and  red.  Foetid  discharge  from  the  fauces  and  nares.  Urine 
scanty  and  high-colored. 

Merc.  iod.  riiber.-Livid,  purplish  patches  in  the  thro^. 
Exudation  limited  and  easily  detached;  n^«««y  °"  !«  ^^^*  ^^J" 
Si  Hawking  up  white  and  tough  mucus.  Swelling  of  the 
glands  Prof  use  salivation  with  pressure  in  the  throat  on  swal- 
lowing.    Diphtheritic  symptoms. 

Muriatic  acid.-Marked  redness  all  over  the  body,  or  else 
scanty  euption  interspersed  with  petechia.  The  throat  and 
fauces  are  dark-red  and  swollen,  and  covered  with  a  grayia^^ 
wh'te  exi  dation.  Excessive  dryness  of  the  lips,  -o^*^  -f 
Tongue.  Acrid  discharge  from  the  nose,  exconatmg  the  nosti  Is 
and  upper  lip  {arum,  mere.  cor.).  Pulse  rapid  and  very  feeble 
tnteimSs  every  third  beat  (fourth  beat,  nit.  aad)  Compete 
prostration  of  the  vital  forces.  Constant  inclination  to  slide 
down  in  bed.    Typhoid  symptoms. 

Nitric  acid.-SorenesB  and  swelling  of  the  tonsils  ^ith  diffi- 
cult deglutition.  Dryness  and  intense  burning  in  the  mouth  and 
fences  Foetid  odor  from  the  mouth  (b«p/..  mere).  Profuse 
S  ;rge  oTthin,  purulent  matter  from  the  nostrils  Offensive 
purS  discharge  from  the  ear  (sil).  Swelling  of  the  parotid 
and  sub-maxillary  glands  (mere). 

Opium.-Drowsiness  or  sopor.  Complete  loss  of  conscious- 
ness (%os.)  with  slow,  stertorous  breathing.  ^^^P"^  «  ^^^P^f  ff 
^ess  with  frightful  visions.  Bed  feels  hot.  can  hardly  he  on  it 
Drynlsof  tie  throat  with  inability  to  swallow.  Retention  o 
urine  Picking  at  the  bedclothes  {hyos. ).  Impending  cerebral 
I^aralysis. 

Phosphoru8.-Con8tant  sleepiness.    Low  muttering  delirium 
{am.,  hapt,  rhus).    Contracted  pupils  {ophm,  physoshgma). 


sistasKsas^ssBwassr 


■i 

•'i 


f 


-  8r*ihtg.iw.iii-i;iiiiii-iii  iri«irii8iiiiiiiWi  %« 


436 


LECTURE8  ON  FEVERS. 


Sudden  disapponrnnce  of  eruption  with  nlnrming  chest  symp- 
toniH.  Difliculty  of  hearing,  especially  of  the  human  voice 
{silicm).  Dry,  immovable  tongue,  cracked  and  covered  wi;>h 
Kordes  ( ms.,  rcrat  alb. ).  Thirst  with  desire  for  very  cold  drinks 
{rhns).  Burning  sensation,  causing  a  constant  change  oi"  posi- 
tion. (Edema  of  the  lids  and  around  the  eyes  {apis,  rhus). 
Brown  urine,  depositing  a  brick-dust  sediment  {cinch.,  h/c). 
Small,  quick,  easily  compressed  pulse.  Ecchymoses.  Failing 
off  of  the  hair  {graph.,  lye.) 

Phosphoric  acid.— Perfect  indifference  {cinch.,  hje.).  Dry- 
ness of  the  mouth  and  throat  {mix).  Bleeding  from  the  nose 
{ham.,  ledum).  Meteoristic  distension  of  tlie  abdomen  with 
rund)ling  and  gurgling.  Invohuitary,  whitish-gray  stools.  Fre- 
quent, small,  feeble  pulse.  Bluish-red  spots  on  the  parts  upon 
which  the  patient  lies.     Ecchymoses. 

Pliytolacca.— Great  prostration  with  violent  pains  in  the 
head,  back  and  extremities.  Dryness  of  the  throat  with  swell- 
ing of  the  tonsils  {bell. ).  Dark  red  color  of  the  fauces  {bapt. ). 
Feeling  as  of  a  lump  in  the  throat,  and  great  pain  at  the  root  of 
the  tongue  when  swallowing  {bell,  lach.).  Thick,  white  and 
yellow  exudation  upon  the  fauces  {kali  bich.).  Shooting  pains 
through  both  ears  when  swallowing.  Hardness  of  the  glands  in 
the  right  side  of  the  neck.  Eheumatic  pains  in  the  extremities. 
The  eruption  appears  dry  and  shriveled;  the  skin  feels  dry  and 
harsh,  like  brown  paper.     Diphtheritic  symptoms. 

Rlllis  tox.— Great  restlessness  and  uneasiness  {ars.).  Active 
delirium  and  great  prostration.  Dry,  red,  cracked  tongue  {bapt, 
bell).  Redness  of  the  tip  of  the  tongue  in  the  shape  of  a  tri- 
angle. Dark  red,  livid  eruption  with  increasing  fever  and  great 
nocturnal  restlessness.  Ichorous  discharge  from  the  nostrils. 
Swelling  and  induration  of  the  parotid  and  sub-maxillary  glands. 
Great  thirst  for  cold  drinks  {phos.),  especially  cold  milk.  In- 
voluntary foetid  stools  during  sleep.  Rheumatic  pains  in  the 
limbs  and  joints.  Itching  over  the  whole  body  {sulphur).  Ves- 
icular  eruption  with  itching  and  burning.    Typhoid  symptoms. 

Secale.— Constant  sighing.  Great  prostration  and  extreme 
restlessness.  Mania  with  inclination  to  bite  {bell,  siram.). 
Aversion  to  being  covered.  Fear  of  death  {ars.).  Brown  or 
blackish  tongue  {ars.).    Violent,  unquenchable  thirst.    Invol- 


ws^ma^&immemimisnm&Kii^jmmsms^mmmm^ 


>' 


ii' 


;<it»«a;i 


LEADING   INDICATIONS. 


437 


!hest  symp- 
aiutin  voice 
n'ered  wiuh 
cold  drinks 
ige  oi'  posi- 
apis,  rhus). 
inch.,  hfc). 
38.    Falling 

lye).  Dry- 
in  the  noHO 
lomen  with 
itools.  Fre- 
I  parts  upon. 

lins  in  the 
with  swell- 
ces  (hapt). 
t  the  root  of 
white  and 
rating  pains 
»e  glands  in 
extremities, 
sels  dry  and 

s. ).  Active 
agVLe{baj)t., 
ipe  of  a  tri- 
»r  and  great, 
he  nostrils, 
lary  glands. 

milk.  In- 
ains  in  the 
hur).    Ves- 

symptoms. 

id  extreme 

l,  siram.). 

Brown  or 

rst.    Invol- 


untary diarrhea  {htiosf.).     Suppression  of  urine.     Blo(xly  and 
albuminous  urine  (/</r/>jn//t.).     Extensive  ecchymoses. 

Sillcea.— Induration  of  glands  from  tardy  convalescencp. 
Swelling  and  BUi)puration  of  the  i)arotid  gland.  Caries  of  the 
mastoid  process.  Otalgia  with  drawing,  stitching  pains  {piih. ). 
Itching  in  Eustachian  tubes  and  ears,  especially  when  swallow- 
ing. Great  sensitiveness  to  cold  air  {ncpia),  takes  cold  easily. 
Disposition  to  boils.     In  scrofulous  children. 

Stranionilim.— Convulsions  excited  by  touch,  or  from  l»>oking 
at  bright,  shining  objects.  Coppery-red  eruption  with  heat,  dry- 
ness and  itching  of  the  skin.  Great  dryness  of  the  throat.  Vio- 
lent thirst,  especially  for  sour  drinks  {hry.,  secalc).  Yellowish- 
brown  coating  on  the  ttmgue,  which  is  dry  in  the  center  {hapt). 
Black  stools  which  smell  like  carrion  {ars.,  carbo.  vqj. ).  Constant 
restlessness  with  jerking  motions  of  the  whole  body.  Suppres- 
sion of  urine. 

Suliniur.— During  the  stage  of  desquamation,  and  in  slowly 
progressing  cases.     In  scrofulous  children. 

Terebinthina.— Headache  with  intense  pressure  and  fullness 
of  the  head.  Slowly  appearing  eruption.  Tongue  red,  smooth 
and  glossy.  Great  drowsiness.  Vomiting  of  mucus,  bile  or 
blood,  aggravated  by  drinking.  Burning  and  drawing  from  the 
right  kidney  to  the  hip.  Urine  smoky  and  turbid,  depositing  a 
sediment  like  coffee  grounds.  Albuminuria  and  luBinaturia. 
.Strangury  {canik).  Intestinal  catarrh  and  diarrhea.  Anasarca 
{hell).    Ascites  {apocynnm  can.). 

Veratrum  vir.— Muttering  delirium.  Restless  sleep  with 
dreams  of  being  drowned.  Severe  frontal  headache  with  vomit- 
ing. Red  streaks  in  the  middle  of  the  tongue;  yellow  edges. 
Intense  fever  with  flushed  face  and  convulsive  twitchings  of  the 
facial  muscles.  Sudden  spasms  with  nausea  and  vomiting  and 
great  prostration.  The  child  trembles  as  if  frightened  and  on 
the  verge  of  spasms.  Convulsions  precede  the  outbreak  of  the 
eruption.  Irregular,  hard,  frequent  pulse.  Oppression  of  the 
chest  with  slow,  labored  breathing.  Dark,  turbid,  foetid  urine. 
Rheumatism. 

Zincum.— Retrocession  of  the  eruption  {ciq^rum).    Threat- 
.ened  paralysis  of  the  brain.    Twitching  of  the  hands  and  feet 


;.imiJ.U..J.J.-l.1«MI"'J.M)J  i'.' 


•ammmmmmm 


438 


LECTURES  ON   FKVEnS. 


Dryness  of  tlio  tliront  with  nccumuliitinn  of  mnciis  in  tho  pos- 
terior iinres.     Snuill,  filiform  pulse.     Involuntary  evacuations. 

HYGIENIC  AND    DIETETIC   THEATMENT. 

Tho  sick  rtM)m  should  be  Inryo  ami  well  ventilated,  and  tho 
teniporature  should  be  kept  betwei>u  65°  Fahr.  and  70"  l-'uhr. 
All  superfluous  articles  of  furniture  and  everytliing  that  is  liable 
to  absorb  and  retain  contagion  should  be  removed  frt>m  the 
apartment.  Throughout  the  whoUi  course  of  the  disease  quiet- 
ude and  the  strictest  cleoiUiness  should  be  observed.  The  bod 
and  room  should  be  sprinkled  with  Plott's  chlorides,  diluted  one 
part  to  ten,  or  some  other  disinfectant.  Sheets  saturated  with 
some  disinfecting  solution  should  be  hung  up  in  the  door  and 
window  ways  of  the  apartment.  The  bed  and  body  linen  should 
be  changed  daily,  and  immediately  thrown  into  a  vessel  contain- 
ing a  solution  of  carbolic  acid,  before  being  removed  from  th» 
room.  The  discharges  from  the  bowels  or  kidneys  should  be 
received  into  vessels  charged  with  disinfectants,  and  immedi- 
ately disposed  of. 

Cool  or  cold  drinks  in  small  amounts  and  at  short  intervals  are 
beneficial  as  well  as  grateful  to  the  patient.  Pieces  of  ice  held 
in  the  mouth  afford  the  most  marked  relief  when  throat  compli- 
cations are  severe.  The  diet  should,  as  a  rule,  be  liquid,  and 
may  consist  of  milk,  milk  and  lime  water,  beef  tea  (p.  193),  but- 
termilk, koumyss,  clam  broth,  light  soups,  or  farinaceous  food. 
If  exhaustion  is  great,  brandy  with  milk  (p.  306),  beef  or  chicken 
tea  and  wine  whey  (p.  194)  may  be  given.  When  diphtheria 
occurs  as  a  complication,  brandy  or  whisky,  should  be  admin- 
istered in  teaspoonf ul  doses  every  hour  or  two,  or  until  the  sys- 
tem becomes  saturated. 

The  local  treatment  of  the  throat  consists  in  the  early  appli- 
cation of  a  cold  water  compress  to  the  front  of  the  neck  from 
ear  to  ear.  When  there  is  considerable  infiltration  of  the  throat, 
hot  applications  externally  and  steam  inhalations,  warm  gargles, 
or  sprays  internally  are  of  the  greatest  benefit.  If  exudation 
occurs,  carbolized  lime  water  spray  (cold)— carbolic  acid  three 
drops,  lime  water  one  ounce — used  three  or  four  times  in  twenty- 
four  hours,  for  three  or  four  minutes  at  a  time,  is  exceedingly 
efficacious.  Viscous  secretions  which  collect  in  the  fauces  should 
be  removed  with  a  camel's  hair  brush.    When  diphtheria  and 


iH«i«a 


i 

"t 

H 


Ft 


HYOIENrC  AND   DIETETIC  TREATMENT. 


■1:59 


in  tho  pos- 
JvacuatioiiH, 

|ated,  mid  thr> 
and  70^  Full,.. 
|g  that  in  linhlo 
'ved  from  tJie 
disease  quiot- 
ved,    Tiie  bed 
Bs,  diluted  one 
saturnted  with 
tJie  door  and 
ly  linen  sliould 
vessel  contain- 
oved  from  the 
eys  shoultl  be 
and  immedi- 

rt  intervals  are 
pes  of  ice  held 
throat  compli- 
be  liquid,  and 
\(P.  193),  but- 
rinaceous  fcxxL 
>eef  or  chicken 
len  diphtheria 
lid  be  admin- 
until  the  sys- 

le  early  appli. 
lie  neck  from 
I  of  the  throat, 
warm  gargles. 
If  exudation 
'lie  acid  three 
les  in  twenty- 
8  exceedingly 
fauces  should 
phtheria  and 


scarlet  fever  are  combined,  a  Holution  of  {H>tnRHinni  poriiwin^aniito 
or  of  li(pior  {H)taH8iD  and  linm  water — one-half  of  a  dnu-hm  to 
four  ounces — administered  in  th((  form  of  spray  by  tlie  atoniizer, 
should  be  used.  When  there  is  onornious  swelliuj^ot'  the  glands 
Im»1ow  and  behind  the  angle  of  the  jaw,  or  when  coryza  Ik  pres- 
ent, tiie  nasal  passages  slumld  be  cleansed  by  means  of  a  canul's 
hair  bnisli,  or  by  the  injection  of  a  mildly  carl)oli/ed  wasli,  and 
then  freely  anointed.  When  there  is  much  purulent  discharge 
from  the  meatus,  frequent  syringing  with  warm  water  should  bo 
employed.  When  suppuration  of  the  external  glands  or  tissues 
about  the  neck  cannot  be  prevented,  hot  fomentations  should  be 
resorted  to,  and  the  abscesses  opened  early. 

When  in  the  early  part  of  the  disease  the  temperature  runs  up 
to  104"  Fahr.,  the  external  use  of  cix)l  or  tepid  water  should 
be  resorted  to.  The  water  may  be  employed  either  by  immer- 
sion in  a  bath  ten  degrees  below  that  of  the  patient,  by  wrapping 
the  patient  in  a  sheet  wrung  out  in  water  at  a  temperature  of  70 ' 
Fahr.,  or  by  sponging  the  surface  with  cold  or  tepid  water. 
Cloths  wrung  out  of  water  at  a  temperature  of  85°  Fahr.  or  90^ 
Fahr.,  applied  to  the  surface,  and  changed  every  hour  or  two, 
are  frequently  used  instead  of  either  the  full  bath  or  the  pack. 
As  in  typhus  fever,  when  the  full  bath  is  used  the  patient  muf-t 
be  kept  in  the  bath  until  his  temperature  falls  to  101°  Fahr., 
then  taken  out,  quickly  dried  and  placed  in  bed.  As  soon  as  the 
temperature  rises  to  lOi''  Fahr.  the  patient  must  receive  another 
bath.  The  best  results,  however,  are  generally  obtained  from 
either  the  wet  sheet,  the  sponging  or  the  application  of  icet  cloths. 

When  there  is  much  itching  and  burning  of  the  skin,  the  sur- 
face should  be  gently  anointed  with  mildly  carbolized  vaseline. 
During  desquamation,  night  and  morning  inunctions  preceded 
by  warm  baths,  are  highly  beneficial. 

When  the  kidneys  are  involved,  large,  hot  poultices  prove  effi- 
cacious. Daily  microscopical  and  chemical  examination  of  the 
urine  should  be  instituted.  If  oedema  occurs,  the  patient  should 
be  given  a  hot  bath  or  a  moist  warm  pack  for  at  least  two  hours, 
then  removed  t)  a  warm  room  with  the  temperature  at  72°  Fahr. 
or  75^  Fahr.,  and  kept  in  bed  with  sufficient  covering  to  induce 
constant,  gentle  perspiration.    Should  the  oedema  become  ex- 


I* 


'I 
I 

If 


LtCTUllJiM   ON   i'EVKllH. 

coHHivo,  Huuill  punctures  iimy  bo  uxnde  in  the  lower  part  i.f  tho 
le^'H  to  fiivor  the  riMuoviil  of  tli<>  fluid. 

Ail  »<x|)<)Hurn  to  cold  Hli«)uld  !)<•  ciircfully  avoid»id,  iind  tho  \m- 
ticiit  Hhould  not  l)o  allowed  to  it'uvo  his  room  for  tliree  or  four 
M-eeJiM  at  least  from  the  i)e>,'iiiiiiiig  of  tlie  attiu-lv. 

During  convuloBcouco,  warm  clothing  should  be  worn. 


^  \\  •:  ■■»  I 


It 
I 

a. 


T  't. 


It 

t 


I'  imrt  (if  tlio 

luul  tho  pn- 
tlirt'p  or  four 

fOTU. 


Blbliograpliy. 

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tfiittent  Fever.     Detroit     ISTO.  ,,  i    •    tt^  i!«n 

Allen.  Dn.  T.  P.    Encyclopedia  of  Pure  Materm  Mea.ca 
Aitkin,  Dr.  William.    The  Science  and  Practice  of  Medi- 

cine.     London.    1880.  , 

B^EHU,  DR.  Beunhard.    The  Science  of  Therapeutics,  accord- 

ing  to  the  Principles  of  Homoeopathy.    New  York.     187^. 
Bartlet.  Dr.  Ellhha.    The  History,  Diagnosis  and  1  n^tment 

of  the  Fevers  of  the  United  States.     Philadelphia.     18.,2. 
Bartholow,  Dr.  Koderth.    A  Manual  of  Hypodermatic  Med- 

ication.    Philadelphia.    1882.  ,,     ^      ,■       t  M«rl 

Bartholow,  Dr.  Rodertr.    A  Treatise  on  the  Practice  of  Med- 

'^^  Bayeh,  Dr.  William.  Typhoid  Fever,  and  Use  of  Baptisia 
Tinctoria.     London.    1872.  .   , 

Bennet.  Dr.  J.  Hughes.  Clinical  Lectures  on  the  Pnuciples 
and  Practice  of  Medicine.     New  York.    1872. 

Blackley.  Dr.  Charles  H.  Hay  Fever;  its  Causes  and 
Treatment.     London.    1880. 

BoTKlN.  M.  S.    DelaFi6vre.     Pans.     1872. 

Bristgwe,  Dr.  John  S.  A  Treatise  on  the  Theory  and  Prac 
tice  of  Medicine.    Philadelphia.    1876.  r^u-    „„ 

Burt,  Dr.  W.  H.    Physiological  Materia  Medica.    Chicago. 

^^BuDD,  Dr.  William.    Typhoid  Fever;  its  Nature,  Mode  of 
Spreading,  and  Prevention.    London.    1874. 
Carter,  Db.  H.  Vandyke.    Spirillum  Fever.   London.  J882. 


r  -^--wpjK*^^-'' 


I.ECTU11E8  ON  FEVEBS. 

CowPERTHWAiTE.  A.  C.    Elementary  Text  Book  of  Materia 
Medica.     Chicago.     1882. 
CoHN,  Dr.  Ferdinand.    Bacteria.    Translation.    1881. 
Castan,  M.  a.    Traite  E16mentaire  des  Fifevres.    Paris.    1872. 
Day,  Dr.  William  H.    Diseases  of  Children.    Philadelphia. 

1881. 

DoBBELL,  Dr.  Horace.  Reports  on  the  Progress  of  Practical 
and  Scientific  Medicine  in  Different  Parts  of  the  World.  Lon- 
don.   1871. 

DoLAN,  Dr.  Thomas  M.    Vaccination;  its  Place  and  Power. 

London     1883. 

DowELL,  Dr.  On  Yellow  Fever.     Philadelphia.     1876. 

Drury,  Dr.  William  V.    Eruptive  Fevers.    London.    1877. 

Duncan,  Dr.  T.  C.  A  Text  Book  on  the  Diseases  of  Infants 
and  Children.     Chicago.     1882. 

Edmonds,  Dr.  W.  A.  A  Treatise  on  Diseases  peculiar  to  In- 
fants and  Children.    Philadelphia.     1881. 

Edwards,  Dr.  JosEPh  F.  Vaccination;  arguments  pro  and 
con.    Philadelphia.    1882. 

Flint,  Dr.  Austin.  A  Treatise  on  the  Principles  and  Prac- 
tice of  Med'.cine.    Philadelphia.     1881. 

Gregory,  Dr.  George.  Lectures  on  the  Eruptive  Fevers 
New  York.    1851. 

Gresinger,  Wilhelm.     Traite  des  Maladies    Infectieuses. 

Paris.     1868. 

Hale,  Dr.  Edwin  M.  Materia  Medica  and  Special  Therapeu- 
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delphia.   1881. 

Hardaway,  Dr.  W.  A.    Essentials  of  Vaccination.    Chicago. 

1882. 

Hartshorne,  Dr.  Henry.  Essentials  of  the  Principles  and 
Practice  of  Medicine.     Philadelphia.     1881. 

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Hering,  Dr.  C.    Treatment  of  Typhoid  Fever 

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Hudson,  Dr.  A.  Lectures  on  the  Study  of  Fever.  Philadel- 
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immmmmimmKmmmiii' 


1^ -■-,,,.  1,  ,«,...■,-.    -...ar.,. 


"Tra* 


BIBLIOGRAPHY. 


443 


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"  Lyons!  DirE.  T.    A  Treatise  on  Eelapsing  or  Famine  Fever. 

'^mILn.'dr.'anxoine.     The  Bacteria.    Translation.     Boston. 

^Teigs  anp  Pepper.    A  Practical  Treatise  on  the  Diseases  of 

"'Sel,  T^t\^olv^^   on  Hemorrhagic  Malarial 

"ZN.E'^DrCHlR^.' V^^^^^  «-;-^- 

MURCHI80N.  DR.  C.     A  Treatise  on  the  Continued  Fevers  of 
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NiEMEYER.  FELIX  VON.  A  Text-Book  of  Practical  Medicine- 
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Etiology  of  some  Common  Diseases.    1880. 


nHfLlLiUlWHBIWW 


'■~0!^i>i$t&i^i!^^-' 


i 


444 


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Philip,  Dr.  A  Treatise  on  Fevers,  including  Eruptive  Fe- 
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Eaue,  Du.  Charles  G.  Special  Pathology  and  Diaguocis, 
with  Therapeutic  Hints.     Philadelphia.    1882. 

Roberts,  Du.  F.  T.  The  Theory  and  Practice  ct  x^todicine. 
Philadelphia.    1881. 

Ruddock,  Dr.  E.  Harris.  The  Family  Doctor,  American 
Edition,  with  Notes  and  Additional  Chapters  by  Dr.  J.  E. 
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Salisbury,  Dr.  J.  H.  Microscopical  Examinations  of  Blood 
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and  Childhood.    Philadelphia.     1876. 

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Schmidt,  Dr.  H.  D.  The  Pathology  and  Treatment  of  Yel- 
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Tommassi-Crudelli,  C.  Bacillus  Malarise  of  Selinunte  and 
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S 


itii.i  i<li[ltiilt»Kiiiiiinin   I,, 


Eruptive  Fe- 
i  Diaguocis, 
cf  x^todicine. 


r,     American 
)y  Dr.   J.E. 

0118  of  Blood 
phoid  Fever. 

es  of  Infancy 

man  Temper- 

ment  of  Yel- 
licago.  1881. 
Pliiladelphia. 

of  Medicine. 

^elinunte  and 

sr  of  the  Air. 

1882. 
ales  and  Prac- 
phia.    1872. 
368  of  Infancy 

tinned  Fevers. 

mty-five  Rem- 

►. 

Q.    1871. 

icine.    Trans- 


INDEX. 


Abortive  typhoid  fever,  147. 
Abscesses,  in  relapsing  fever,  314. 

in  typhoid  fever,  150. 

in  yellow  fever,  202. 
Age,  in  etiology  of  cerebro-spinal 
fever,  224. 

in  etiology  of  typhoid  fever,  138. 

of  person  to  be  vaccinated,  366. 

Ague,  48 

Albuminuria,  in  scarlet  fever,  419. 
in  typhoid  fever,  158 


Apyretic  intervals,  in  simple  inter- 
mittent fever,  51. 
in  relapsing  fever,  313. 
Arachnoid,  condition  of,  in  cerebro- 
spinal fever,  234. 
Arthritic  pains  in  relapsing  fever» 
315. 
in  dengue,  105. 
Asthma,  hay,   clinical  history  of,. 

125. 
Bacillus  malarise,  18, 39. 


ivigm,  yai.i^^'j      f       „i.j„i„„„  „*  tv      definition  of,  16. 


Alcohol,  excess  of.  in  etiology  of  ty 

phoid  fever,  169. 
America,  invaded  by  scarlet  fever, 

404. 
by  small-pox,  332. 
Anaemia,  after  relapsing  fever,  315. 
Analysis  of  chart,  of  cerebro-spmal 
fever,  227. 
of  dengue,  106. 
of  hay  fever,  128. 
of  influenza,  256. 
of  measles,  383. 
of  pernicious  fever,  93. 
of  relapsing  fever,  315. 
of  scarlet  fever,  414. 
of  simple  continued  fever,  31. 
of  simple  intermittent  fever,  53 
of  simple  remittent  fever,  80. 
of  small-pox,  .341. 
of  typhoid  fever,  148. 
of  typho-malarial  fever,  115. 
of  typhus  fever,  281. 
of  yellow  fever,  203. 
Anasarca,  in  scarlet  fever,  411. 


definition  of,  16. 
effects  of  boracic  acid  upon,  20. 
effects  of  carbolic  acid  upon,  20. 
effects  of  ozone  upon,  20. 
forms  of,  16. 
in  pneumonia,  23. 
in  ulcerative  endocarditis,  23. 
reproduction  of,  18. 
where  found,  20. 
Bacterium,  the  weight  of  a,  21. 
Bedsores,  in  typhoid  fever,  157. 

in  typhus  fever,  281. 
Beef  essence,  formula  for,  190. 
Beef  tea,  formula  for,  193. 
Bibliography,  441. 
Bilious  remittent  fever,  80. 
Black  vomit,  in  yellow  fever,  207. 
Blood,  changes  in,  in  cerebro-spinal 
fever,  233. 
in  chronic  malarial  infection,  101. 
in  measles,  389. 
in  miliary  fever,  376. 
in  pernicious  fever,  96. 
in  relapsing  fever,  321. 

(445) 


I 

ffl! 
i 


% 


446 


INDEX.' 


in  scarlet  fever,  421. 
in  simple  intermittent  fever,  55. 
in  simple  remittent  fever,  82. 
in  typhoid  fever,  162. 
in  typho-malarial  fever,  117. 
in  typhus  fever,  289. 
in  yellow  fever,  20!). 
Boils,  in  typhoid  fever,  167. 

in  typhus  fever,  281. 
Boracicacid,  action  of,  upon  bacte- 
ria, 20. 
Bovine  virus,  points  and  slips  for, 

360. 
Bowels,  hemorrhage  from,  in  typhoid 
fever,  151. 
in  yellow  fever,  205. 
Brain,  changes  in,  in  cerebro-spinal 
fever,  234. 
in  typhoid  fever,  163. 
in  typhus  fever,  290. 
in  yellow  fever,  209. 
Bronchitis,  in  influenza,  258. 

in  typhus  fever,  288. 
Bror^^ed  liver,  in  simple  remittent 

fever,  83. 
Cfficum,  lesions  of,  in  relapsing  fever, 

321. 
in  typhoid  fever,  164, 
Catarrh,  bronchial,  in  influenza,  265. 

in  typhoid  fever,  166. 
Catheter  ism,  in  typhoid  fevor,  158. 
Carbolic  acid,  action  of,  upon  bacte- 
ria, 20, 
Carbon,  how  obtained,  by  bacteria, 

20. 
Cerebro-spinal  fever,  chart  of,  228. 
clinical  history  of,  226. 
complications  of,  233. 
dettnition  cf ,  223. 
differential  diagnosis  of,  235. 
etiology  of,  224. 
history  of,  223. 
morbid  anatomy  of,  233. 
prognosis  of,  237. 
Bchizomycetes  in,  23. 
synonyms  of,  223. 
treatment  of,  239. 
varieties  of,  225. 
Chart  of,  cerebro-spinal  fever,  228. 


of  chicken  pox,  373. 
of  dengue,  107. 
of  german  measles,  401. 
of  influenza,  257. 
of  hay  fever,  128. 
of  measles,  385. 
of  miliary  fever,  377. 
of  pernicious  fever,  94. 
of  relapsing  fever,  316 
of  scarlet  fever,  415. 
of  simple  continued  fever,  32. 
of  simple  intermittent  fever,  63. 
of  simple  remittent  fever,  81. 
of  small-pox,  342. 
of  typhoid  fever,  149. 
of  typho-malarial  fever,  116. 
of  typhus  fever  282. 
of  varioloid,  309. 
of  yellow  fever,  204. 
Chart,  temperature,  of  simple  con- 
tinued fever,  33, 34. 
of  relapsing  fever,  319. 
of  typhoid  fever,  153, 165, 161. 
of  typhus  fever,  285. 
of  yellow  fever,  207. 
Cheyne-Stokes  respiration  in  cere- 
bro-spinal fever,  228. 
Choleraic  variety  of  pernicious  fever, 

92. 
Clioriditis  after  relapsing  fever,  315. 
Chicken-pox,  chart  of.  373. 
clinical  history  of,  371. 
definition  of,  371. 
differential  diagnosis  of,  372. 
duration  of,  372. 
etiology  of,  371. 
history  of,  371 
incubation  of,  371. 
prognosis  of,  372. 
synonyms  of,  371. 
treatment  of.  372. 
Chronic  malarial  infection,  definition 
of,  100. 
clinical  h  story  of,  100. 
differential  diagnosis  of,  102. 
etiology  of,  100. 
morbid  anatomy  of,  101. 
prognosis  of,  102. 
synonjTns  of,  100. 


IMMHIMI 


I 
r 

it 


INDEX. 


447 


01. 


94. 
10 

fever,  32. 
int  fever,  53. 
fever,  81. 

I. 

ver,  116. 


of  simple  con- 

4. 

319. 

3, 155, 161. 


ration  in  cere- 

228. 

emicious  fever, 

sing  fever,  315. 

f .  373. 

371. 

sis  of,  372. 


iction.  definition 

,100. 

)si3  of,  102. 

»f,  101. 


treatment  of,  102. 
Classification,  of  bacteria,  17. 

CUmate!in  ecology  of  cerebro-spinal 
fever,  224. 

of  typhoid  fever,  137. 

of  typlius  fever.  274. 
Clinical  history, of  cerebro-spmal  fe 

ver,  226. 
of  chicken-pox,  371. 
of  chronic  malarial  infection,  100. 
of  cow-pox,  360. 
of  dengue,  104. 
of  german  measles,  4W. 
of  influenza,  255, 
of  inoculation,  364. 
of  hay  fever,  125. 
of  measles,  381. 
of  miliary  fever,  375. 
of  pernicious  fever,  90. 
of  relapsing  fever,  312. 
of  scarlet  fever,  407. 
of  simple  continued  fever,  29. 
of  simple  intermittent  fever  49 
of  simple  remittent  fever,  77. 
of  small-pox,  336. 
of  typhoid  fever,  142. 
of  typho-malarial  fever,  li.^. 
of  typhus  fever,  276. 
of  vaccinia,  361. 
of  varioloid,  368. 
of  yeUow  fever,  200. 
Cold  appUcations,  in  scarlet  fever, 

438. 
ill  typhoid  fever,  191. 
in  typhus  fever,  305. 
Colliquative  variety  of  pernicious  fe- 

Coma^in  cerebro-spinal  fever  f9. 
Coma  vigil,  in  typhus  fever,  283. 
Comatose  variety  of  pernicious  fe- 

ver,  90. 
Confluent  small-pox,  339. 
Constipation  in  typhus,  289. 

Contagion,  definition  of,  28. 
in  measles,  380. 
in  relapsing  fever,  310. 
in  scarlet  fever,  405. 
in  small-pox,  334. 


in  typhoid  fever,  140. 

in  typlius  fever,  274. 

in  yellow  fever,  197. 
Contagiumvivum,16. 
Contagious  fevers,  definit  on  of ,  -8. 
Convulsions,  in  cerebro-spinal  fever, 

229. 
in  pernicious  fever,  93. 
in  scarlet  fever,  416. 
in  typhoid  fever,  159. 
in  typhus  fever,  284. 
Cornea,  ulceration  of ,  in  scarlet  fe- 
ver, 420. 
in  small-pox,  341. 
Cough,  in  influenza,  258. 
in  measles,  386. 
in  typhoid  fever,  156. 
Countenance,  in  influenza,  2o5. 
in  small-pox,  338. 
in  typhoid  fever,  143. 
in  typhus  fever,  276. 
in  yellow  fever,  200. 
Cow-pox,  clinical  history  of,  3W) 
definition  of,  360. 
etiology  of,  360. 
history  of,  360. 
synonyms,  360. 
Coze  and  Feltz,  experiments  of,  upon 

bacteria,  22. 
Critical  days,  44. 
Crisis  in  typhus  fever,  286. 
Cutaneous  lesions,  m  cerebro-spinal 
fever,  231. 
in  chicken-pox,  371. 
in  measles,  387. 
in  miliary  fever,  376. 
in  scarlet  fever,  418. 
in  small-pox,  343. 
in  typhoid  fever,  157. 
in  typhus  fever,  287. 
in  varioloid,  368. 
in  yellow  fever,  203. 
Cystitis  in  typhoid  fever,  158. 
Daafness,  after  cerebro-spinal  fever. 

233. 
after  scarlet  fever,  413. 

in  typhoid  fever,  159. 
in  typhus  fever,  284. 
Death-point  of  bacteria,  18. 


i 


,p,)i   I       iiiiiiwriw 


J 

•I 

I}. 


INDEX. 


Definition,  of  bacteria,  16. 

of  cerebro-spinal  fever,  223. 

of  cliicken-pox,  371. 

of  chronic  malarial  infection,  100. 

of  cow-pox,  a(iO. 

of  dengue,  103. 

of  german  measles,  300. 

of  hay  lever,  123. 

of  inoculation,  364. 

of  intluenza,  253. 

of  measles,  379. 

of  miliary  fever,  374. 

of  pernicious  fever,  89. 

of  relapsing  fever,  307. 

of  scarlet  fever,  404. 

of  simple  continued  fever,  29. 

of  simple  intermittent  fever,  48. 

of  simple  remittent  fever,  76. 

of  small-pox,  331. 

of  typhoid  fever,  136. 

of  typho-malarial  fever.  111. 

of  typhus  fever,  272. 

of  vaccinia,  361. 

of  vaccination,  365. 

of  varioloid,  368. 

of  yellow  fever,  195. 
Deglutition,  difficult,  in  scarlet  fe- 
ver, 417. 

in  typhoid  fever,  160. 

in  typhus  fever,  278. 
Delirious  variety  of  pernicious  fever, 

91. 
Delirium  in  pernicious  fever,  93. 

in  scarlet  fever,  414. 

in  small-pox,  341. 

in  typhoid  fever,  168. 

in  typho-malarial  fever,  116. 

in  typhus  fever,  283. 

in  yellow  fever,  208. 
Dengue  fever,  chart  of,  107. 

clinical  history  of,  104. 

delinition  of,  103. 

differential  diagnosis  of,  108. 

duration  of,  105. 

etiology  of,  104. 

history  of,  104. 

prognosis  of,  108. 

synonyms  of,  104. 

treatment  of,  108. 


Desiccation  in  small-pox,  388. 
Destitution,  as  predisposing  to  re- 
lapsing fever,  809 

to  typhus  fever,  274. 
Desquamation,  in  measles,  S''^. 

in  relapsing  fever,  320. 

in  scarlet  fever,  409. 
Diarrhea,  in  chronic  malarial  infec- 
tion, 101. 

in  relapsing  fever,  818. 

in  scarlet  fever,  419. 

in  typhoid  fever,  150. 

in  typho-malarial  fever,  115. 
Diet,  in  cerebro-spinal  fever,  261 . 

in  clricken-pox,  374. 

in  influenza,  276. 

in  measles,  398. 

in  miliary  fever,  378. 

in  pernicious  fever,  99. 

in  relapsing  fever,  329. 

in  scarlet  fever,  438 

In  simple  intermittent  fever,  76. 

in  typhoid  fever,  192. 

in  typhus  fever,  304. 

in  yellow  fever,  221. 
Difference  between  bacteria  of  con- 
tagion and  bacteria  of  putrefac- 
tion, 21. 
Differential  diagnosis,  of  cerebro- 
spinal fever,  235. 

of  chicken-pox,  372. 

of  chronic  malarial  infection,  102. 

of  dengue,  108. 

of  german  measles,  402. 

of  hay  fever,  129. 

of  influenza,  269. 

of  measles,  390. 

of  miliary  fever,  376. 

of  pernicious  fever,  96. 

of  relapsing  fever,  322. 

of  scarlet  fever,  422. 

of  simple  continued  fever,  33. 

of  simple  intermittent  fever,  55. 

of  simple  remittent  fever,  83. 

of  small-pox,  348. 

of  typhoid  fever,  165. 

of  typho-malarial  fever,  118. 

of  typhus  fever,  291. 

of  yellow  fever,  210. 


INDEX. 


m 


>0X,  338. 
sposing  to  re- 

aslea,  3'''2. 

ao. 

malarial  infec- 

(18. 

). 

iver,  115. 

il  fever,  261. 


i. 

09. 
J29. 

int  fever,  76. 
i. 


acteria  of  con- 
ria  of  putrefac- 

Lb,  of  cerebro- 


infection,  102. 

402. 


t. 

96. 
}22. 

fever,  33. 
5nt  fever,  65. 
fever,  83. 

5. 

5ver,  118. 


Digestive  system,  condition  of,  in 
cerebro-spinal  fever,  2:^2. 
in  chronic  malarial  infection,  115. 
in  dengue,  100. 
In  influenza,  258. 
in  measlea,  888. 
in  pernicious  fever,  »."). 
in  relapsing  fever,  317. 
in  scarlet  fever,  418. 
in  simple  intermittent  fever,  54. 
in  simple  remittent  fever,  82. 
in  small-pox,  345. 
in  typhoid  fever,  148. 
in  typho-malarial  fever,  116. 
in  typhus  fever,  288. 
in  yellow  fever,  203. 
Dimensions  of  bacteria,  17. 
Diphtheria,  aa  a  complication  of 

scarlet  fever,  412. 
Disinfectants,  in  the  treatment  of 
relapsing  fever,  324. 
of  scarlet  fever,  425. 
of  small-pox,  361. 
of  typhoid  fever,  172. 
of  typhus  tever,  293. 
of  yellow  fever,  231. 
Dropsy,  scarlatinal,  411. 

treatment  of,  428. 
Drinking  water,  contamiration  of, 
in  scarlet  fever,  406. 
in  typhoid  fever,  141. 
Duodenum,  lesions  of,  in  typhoid  fe- 
ver, 163. 
in  scarlet  fever.  422. 
Dura  mater,  condition  of,  in  cerebro- 
spinal fever,  234. 
in  typhoid  fever,  163. 
Dyspnoea,  of  cerebro-spinal  fever, 
226. 
of  hay  fever,  129. 
of  influenza,  258. 
of  miliary  fever,  375. 
Ear,  disorders  of,  in  cerebro-spinai 
fever,  229. 
in  scarlet  fever,  420. 
in  small-pox,  341. 
in  typhoid  fever,  159. 
in  typhus  fever,  284. 
Eczema,  after  vaccination,  363. 


Emaciation,  in  dt-ngiu-,  108. 

in  typhoid  fever,  157. 
Endocarditis,  in  cerebro-spinal  fe- 
ver, 233. 
in  small-pox,  383. 
Epididymitis,  in  dengue,  100. 

in  small-pox,  340. 
Epistaxis,  in  typhoid  fever.  159. 
Eruption,  of   cerebro-spinal  fever, 
231. 
of  chicken-pox,  ;?71. 
of  dengue,  106. 
of  german  measles,  400. 
of  measles,  387. 
of  miliary  fever,  370, 
of  relapsing  fever,  320. 
of  scarlet  fever,  42(t. 
of  small-pox,  343. 
of  typhoid  fever,  107. 
of  typhus  fever,  287. 
of  varioloid,. 368. 
Erysipelas,  after  vaccination,  HC^X 
Erythema,  iu  cerebro-spinal  fever, 

231. 
Etiology,  of  cerebro-spinal  fever.  2-j4. 
of  chronic  malarial  infection,  100. 
of  chicken-pox,  371. 
of  cow-pox,  300. 
of  dengue,  104. 
of  german  measles,  399. 
of  hay  fever,  124. 
of  influenza,  254. 
of  measles,  380. 
of  miliary  fever,  375. 
of  pernicious  fever,  90. 
of  relapsing  fever,  309. 
of  scarlet  fever,  405. 
of  simple  continued  fever,  29. 
of  simple  intermittent  fever,  49. 
of  simple  remittent  fever,  70. 
of  small-pox,  334. 
of  typhoid  fever,  137. 
of  typho-malarial  fever,  112 
of  typhus  fever,  274. 
of  varioloid,  368. 
of  yellow  fever,  196. 
Excreta,  decomposing,  in  etiology  of 

typhoid  fever,  141. 
Eye,  condition  of,  in  cerebro-spinal 


fl 


mmmi0»--i 


Pf,jS5w*i«EF>-«W^'- 


450 


INDEX. 


fever,  220. 
In  hay  lever,  127. 
in  influenza,  225. 
in  measles,  381. 
in  relapsing  fever,  313. 
in  scarlet  fever,  419. 
In  small-pox,  341. 
in  typhoid  fever,  16fl. 
in  typhus  fever,  284. 
in  yellow  fever,  2a5. 
Fever,  ardent  continued,  30. 
asthenic  simple,  31. 
corebro-Bpinal,223. 
dengue,  103. 

ephemeral  continued,  30. 
miliary,  874. 
pernicious,  89. 
scarlet,  404. 

simple  intermittent,  48. 
simple  remittent,  70. 
synochal  continued,  30. 
relapsing,  307. 
typhoid,  135. 
typhus,  272. 
yellow,  195. 
Fevers,  classification  of,  28. 
contagious,  definition  of,  28. 
introduction  to,  15. 
malarial,  35. 
miasmatic,  27. 
miasmatic,  contagious,  27. 
Fomites,  in  measles,  380. 
in  relapsing  fever,  311. 
in  scarlet  fever,  406. 
in  small-pox,  335. 
in  typhoid  lever,  139. 
in  typhus  fever,  274. 
in  yellow  fever,  199. 
Forms  of  bacteria,  17. 
Fresh  air  in  treatment,  of  scarlet  te 
ver.  438. 
of  small-pox,  358. 
of  typhoid  fever,  190. 
of  typhus  fever,  304. 
of  yellow  fever,  221. 
Gangrene,  of  lung,  in  typhus  fever, 
290. 
of  tonsils,  in  scarlet  fever,  421 . 
Geographical  limits,  of  malarial  fe- 


vers, 37. 
of  simple  remittent  fever,  77. 
of  typhoid  fever,  137. 
of  typhus  fever,  273. 
of  yellow  fever,  196. 
Gertiis,  of  cerebro-spinal  fever,  225. 
of  malarial  fevers,  18, 3it. 
of  measles,  380. 
of  influenza,  25<'). 
of  relapsing  fever,  310. 
of  scarlet  fever,  405. 
of  small-pox,  834. 
of  typhoid  lever,  138. 
of  typho-malarial  fever,  112. 
of  typhus  fever,  274. 
of  yellow  fever,  107. 
German  measles,  chart  of,  401. 
clinical  history  of,  400. 
definition  of,  399. 
differential  diagnosis  of,  402. 
duration  of,  402. 
etiology  of,  399. 
history  of,  399. 
morbid  anatomy  of,  402. 
prognosis  of,  403. 
synonyms  of,  399. 
treatment  of,  403. 
Glandular  enlargements,  in  dengue, 
100. 
in  typhus  fever,  280. 
Glandular  inflammation  in  scarlet 

fever,  417. 
Gurgling  in  right  iliac  fossa,  in  ty- 
phoid fever,  151. 
llsematuria,  in  pernicious  fever,  97. 
in  scarlet  fever,  419. 
in  small-pox,  340. 
Hair,  falling  of,  in  scarlet  fever,  418. 
iu  typhoid  fever,  157. 
in  typhus  fever,  279. 
Hay  fever,  asthmatic  form  of,  120. 
catarrhal  form  of,  125. 
chart  of,  128. 
clinical  history  of,  126. 
definition  of,  123. 
differential  diagnosis  of,  129. 
etiology  of,  124. 
history  of,  123 
prognosis  of,  130. 


fiiWffiTmiMimi 


■— ^ 


INDEX. 


461 


rever,  77. 


nal  fever,  22.5. 
8,  3i). 


110. 


8. 

9ver,  112. 


rt  of,  401. 
400. 

jis  of,  402. 


:,  402. 


ents,  in  dengue, 

0. 

ition  in  scarlet 

liac  fossa,  in  ty- 

licious  fever,  07. 
9. 

icarlet  fever,  418. 

157. 

79. 

ic  form  of,  126. 

,125. 

:,  125. 

osis  of,  129. 


synonymd  of,  123. 
treatment  of,  130. 
varieties  of,  125. 
Headache,  in  cerebro-spinal  fever, 

227. 
in  chicken-pox,  .371. 

ia  dengue,  100. 
in  german  measles,  400. 
!n  influenza,  2.W. 
in  measles,  .380. 
in  miliary  fever,  375. 
in  pernicious  fever,  00. 
in  relapsing  fever,  315. 
in  scarlet  fever,  414. 
in  simple  intermittent  fever,  53. 
in  simple  remittent  fever,  80. 
in  small-pox,  341. 
in  typhoid  fever,  158. 
in  typho-raalarial  fever,  115. 
in  typhus  fever,  281. 
in  varioloid,  868. 
in  yellow  fever,  206. 
Hearing,  disturbance  of,  in  cerebro- 
spinal fever,  229. 
in  chronic  malarial  infection,  102. 
in  measles,  884. 
in  scarlet  fever,  413. 
in  small-pox,  841. 
in  typhoid  fever,  159. 
in  typhus  fever,  284. 
Heart,  changes  in,  in  chronic  mala- 
rial infection,  101. 
in  relapsing  fever,  321. 
in  typhoid  fever,  162. 
in  typho-malarial  fever,  117. 
in  typhus  fever,  290. 
in  yeWovr  fever,  209. 
condition  of,  in  cerebro-spinal  fe- 
ver, 233. 
Hemiplegia  in  chronic  malarial  in- 
fection, 101. 
Hemorrhage,  in  pernicious  fever,  92 
in  typho-malarial  fever,  115. 
from  intestines,  in  typhoid  fever 
151. 
Herpes,  in  cerebro-spinal  fever,  231 
in  influenza,  258. 
in  simple  continued  fever,  83. 
History  of  bacteria,  13. 


of  cerebro-spinal  fever,  223. 
of  chicken-pox,  371. 
of  cow-pox,  360. 
of  dengue,  104. 
of  german  measles,  ">no. 
of  hay  fever,  123. 
of  hypodermatic  medication,  98. 
of  influenza  253. 
of  inoculation,  304. 
of  measles,  379. 
of  miliary  fever,  374. 
of  pernicious  fever,  89. 
of  relapsing  fever,  308. 
of  scarlet  fever,  404. 
of  simple  intermittent  fever  48. 
of  simple  remittent  fever,  76 . 
of  small-pox,  332. 
of  typhoid  fever,  136. 
of  typho-malarial  fever,  112. 
of  typhus  fever,  273. 
of  vaccination,  365. 
of  yellow  fever,  195. 
Horse-pox,  361. 

Hydrocephalus,  chronic,  after  cere- 
brospinal fever,  227. 
after  scarlet  fever,  412. 
Hygienic  treatment,  of  cerebro-spi- 
nal fever,  251. 
of  chicken-pox,  372. 
of  chronic  malarial  infection,  102. 
of  dengue,  108. 
1    of  german  measles,  403. 
of  hay  fever,  130. 
of  Influenza,  271. 
of  measles,  897. 
of  miliary  fever,  878. 
of  pernicious  fever,  99. 
of  relapsing  fever,  329. 
of  scarlet  fever,  438. 
of  simple  continued  fever,  34. 
of  slmpe  intermittent  fever,  75. 
of  small-pox,  869. 
of  typhoid  fever,  190. 
of  typho-malarial  fever,  121. 
of  typhus  fever,  804. 
of  yellow  fever,  221. 
HyperiBsthesia,  in  cerebro-spinal  fe- 
ver, 231. 
in  typhoid  fever  159. 


|^ii^j«lS«>;i| 


'  "«ww»>s«5fin«»M»-«»''^"' 


452 


INDEX. 


Ilypochoiulriasis,  in  chronic  malarial 

iiil'ection.  lOl- 
Ilypoilermutic  medication,  In  cere- 
bro-splnal  fever.  '2ra. 
in  l"'rniciou3  lever,  iw. 
In  simple  intermittent  fever,  59. 
llysteriii,  in  typhoid  fever,  1.>H. 
Ice-water  injections  int..  rectum  in 

uriniiry  retention.  221. 
Icteric  variety  of  pernicious  fever. 

Ileum,  lesions  of,  in  typhoid  fever. 

1(12.  ,     ,    .  , 

Infarctions,  in  kidneys,  m  typhoid 

fever,  lOi. 
iu  spleen,  in  relapsing  fever,  .5-1 
Influenza,  chart  of,  2.57 
clinical  history  of,  255. 
definition  of .  2r)3 
differential  diagnosis  of,  ^o. 
etiology  of,  2.54. 
history  of,  '2')S 
morbid  anatomy  of,  259. 
prognosis  of,  259. 
synonyms  of,  25.'?. 
treatment  of ,  259. 
Inoculation,  clinical  history  of,  .iW. 
definition  of,  304. 
history  of,  364. 
mortality  of,  3(i.'j 
Insomnia  in  typhus  fever,  ^i. 
Instrument  for  hypodermatic  injec- 
tions, 98.  . 
Intermittent  fever,  neuralgia  m,  ol. 
Intestinal  canal,  lesions  of,  in  mea- 
sles, 389. 
in  miliary  fever,  376. 
in  pernicious  fever,  96. 
in  relapsing  fever,  321. 
in  simple  remittent  fever,  83. 
in  typhoid  fever,  1»>3. 
in  typho-malarial  fever,  117. 
Introductory,  15. 
Inunctions,  in  measles,  398. 
in  scarlet  fever,  439. 
in  small-pox.  359 
Iron  cough  in  measles,  386. 
Jaundice,  in  bilious  remittent  fe%er, 


in  cerebro-spimil  I'l'scr.  23;t. 
in  pernicious  fever.  93. 
in  relapsing  fever,  31H. 
Inematogeuous,  In  yellow   fever, 

203. 
Jenner,  vaccination  and,  365. 
Joints,  affection  of,  in  dengue.  IOh 
infiammatiou  of,  In  cerebro-spmal 

fever,  231. 
in  scarlet  fever.  413. 
Kidneys,  lesions  of,  in  cerebro-spmal 
fever,  234 
iu  chronic  malarial  infection,  101. 
in  pernicious  fever.  92. 
in  relapsing  fever.  321. 
in  scarlet  fever,  421. 
in  typhoid  fever,  162. 
in  typho-malarial  fever,  117. 
in  typhus  fever,  LW. 
in  yellow  fever,  208. 
Koch,  experiments  of,  concerning 
bacteria,  23  .  ^     ,    • , 

Koumyss,  in  treatment  of  typhoi.l 

fever,  193. 
Laryngitis,  in  inlhienza,  2,58. 

in  typhoid  lever.  279. 
Leeuwenhoek  first  to  observe  bacte- 
ria, 10. 
Liver,  changes  in,  in  chronic  mala- 
rial infeclion,  102. 
in  pernicious  fever,  93. 
in  relapsing  fever,  321. 
in  scarlet  fever,  422. 
in  simple  intermittent  fever,  65. 
in  simple  remittent  fever,  83, 
in  typhoid  fever,  162. 
in  typho-malarial  fever,  117. 
in  typhus  fever,  290. 
in  yellow  fever,  208. 
Lungs,  changes  in,  cerebro-spinal  fe- 
ver, 233. 
in  german  measles,  400. 
in  influenza,  258. 
in  measles  389. 
in  pernicious  fever,  93. 
in  relapsing  fever  321. 
in  tyyhoid  fever,  162. 
in  typhus  fever,  290. 


■  i 

'I 

( 


INDEX. 


ev,  1233. 

1)3. 
IK. 
yellow   fevpr, 

Kl, :««. 

n  dengue.  lOH. 

cerebro-spiual 


.  cerebro-spinal 

infection,  101. 
,02. 
321. 


evtr,  117. 

). 

(if,  concerning 
lent  of  typhoi«l 

nza,2o8. 

7tt. 

lo  observe  bacte- 

in  chronic  mala- 

)2. 

r,  93. 

,321. 

DO. 

ttent  fever,  65. 
nt  fever,  83, 
11)2. 

1  fever,  117. 
»0. 
08. 

cerebro-spinal  fe- 
es, 400. 


er,  93. 
■r  321. 
,102. 

290. 


Lymphatic  «1an<lB,  enlargement  of 

In  ilengue,  IWl. 
Malaria,  conditionH  favorable  to  the 

(leve'ttpmeiit  of,  42. 
flinmli'-  inllueuces  In  the  geneslH 

of,  44. 
geographical  limits  of,  37. 
iiicubalionof,  41. 
Husceptibility  to,  41. 
the  laws  of,  40. 
Malarial  fevers,  character  of,  M 
microscopical  appearance  of  blood 

in,  r>'). 
geographical  limits  of,  37. 

origin  of,  37. 
Malignant  measles,  383. 
Mania,  in  cerebro-spinal  fever,  2.0, 

in  scarlet  fever,  414. 

in  small-pox,  311. 

in  typhoid  fever,  IW. 

in  typhus  fever.  283. 
Marson'8  statistics  of  vaccination 

3(M}. 
Martin's  statistics  of  animal  vaccin- 
ation, 307. 
Massage,  in  treatment  of  dengue,  100. 
Measles,  bacteriform  el.  ments  m, 
22, ;  80. 
chart  of,  385. 
clinical  history  of,  381. 
complications  of,  384. 
dennition  of,  370. 
differential  diagnosis  of,  390. 
duration  of,  383. 
etiology  of,  380. 
history  of,  379. 
incubation  of,  380. 
irregular  types  of,  383. 
morbid  anatomy  of,  388. 
prognosis  of,  391. 
sequels  of,  384. 
synonyms  of,  379. 
treatment  of,  301. 
Meat-pancreas  injections  in  typhoid 

fever,  193. 
Meningitis,  as  a  complication  of  ty 

phus  fever,  1:80. 
Memory,  weakness  of,  after  cerebro 
spinal  fever,  233. 


Mesenteric  glands,  changes  in,  in 
typhoid  fever,  W>. 

In  typh«)-malarial  fever,  118. 

in  simple  remittent  fever,  83. 

in  scarh't  fever,  422. 
Meteorism  in  typhoia  f»'ver,  152. 
Miasm.deUnltlonof,  27. 

nature  of,  38. 
Miasmatic  fevers,  denmtion  of  CT. 
MiaHmalic-contagiouB  levers,  deUal- 

tion  of,  27. 
Micrococcus,  description  of,  17. 

Miliary  fever,  chart  of,  377 . 
I  clinical  history  of.  375. 
'     dellnltionof,  374. 

differential  diagnosis  of,  3<tt. 
duration  of,  37t(. 
etiology  of,  375. 
history  of,  374. 
morbid  anatomy  of,  370. 
prognosis  of,  378. 
synonyms  of,  374. 
treatment  of  378. 
Mild  typhoid  fever,  1 17. 
Milk,  in  etiology  of  scarlet  fever» 

406. 
in  etiology  of  typhoid  fever.  142. 
in  treatment  of  typhoid  fever,  192. 
Montague,  lady,  on  small-pox  inocu- 
lation, 3(U. 
Morbid  anatomy,  of  cerebro-spmal 
fever,  233. 
of  chronic  malarial  infection,  loi. 
of  german  measles,  402. 
of  intluenza,  2."»9. 
of  measleH.  3H8. 
of  pernicious  fever,  90. 
of  relapsing  fever,  320. 
of  scarlet  fever,  420. 
of  simple  intermittent  fever,  64. 
of  simple  remittent  fever,  82. 
of  small-pox,  347. 
of  typhoid  fever,  100. 
of  typho-malarial  fever,  117. 
of  typhus  fever,  289. 
of  yellow  fever,  208. 
Muscles,  changes  in,  in  cerebro-spi- 
nal fever,  234. 
in  typhoid  fever,  103. 


M 


1 


1 


454 


INDEX. 


in  typlum  fever,  Lt)0. 

contraction  of,  in  cercl)ro-8j>lnftl 
fever,  UIU). 

piuiilywis  of,  in  typlioid  fever,  VM. 

in  typiiua  fever,  liHj. 
Niiimea,  in  cerebro-Miiinttl  fever,  ISW. 

in  (lenKne,  KHl. 

in  Kerniiin  meaHlea,  4(H». 

in  intlnen/n,  llW, 

in  measles,  IWM. 

In  reluiming  fever,  ."{17. 

in  scarlet  lever,  410. 

In  simplo  Intormitlent  fever,  r>\. 

In  simple  remittent  fever,  »2. 

in  small-pox,  ;!4tt. 

in  typhoid  fever,  l.W. 

in  typho-malarial  fever,  11'). 

In  typhus  fever,  ^sk. 

in  yellow  fever,  iioit. 
Neck,  stiffness  of,  in  cerebro-si)inal 

fever,  2JW. 
Neuralgia,  in  chronic  malarial  infec- 
tion, 101. 

in  inlluenza.  2.')7. 

in  relapsing  fever,  315. 
Nitrogen,  how  obtained  by  bacteria, 

20. 
Odor  of  skin,  in  scarlet  fever,  4is. 

in  simple  intermittent  fever,  54. 

In  small-pox,  338. 

in  typhus  fever,  278. 

in  yellow  fever,  200. 
Occupation,  in  etiology  of  typhoid 
fever,  138. 

in  etiology  of  typhus  fever,  274. 
CEdema,  of  glottis,  in  scarlet  fever, 

412. 

pulmonary,  in  typhoid  fever,  162. 
Orchitis,  in  small-pox,  346. 
Origin,  of  bacteria,  20. 

of  new  diseases  in  the  world,  21. 
Overcrowding,  in  etiology  of  relaps- 
ing fever,  300. 

in  etiology  of  typhus  fever,  274. 
Ozone,  action  of,  upon  bacteria,  20. 
Pain,  in  cerebro-spinal  fever,  231. 

in  chronic  malarial  infection,  101. 

in  dengue,  108. 

in  influenza,  256. 


in  relapsing  fever,  315. 

in  simple  Intermittent  fev«  r  M. 

In  simple  remittent  fever,  77. 

in  small-pox,  341. 

in  typhoid  fever,  158. 

in  typho-miUarlal  fever,  llfi. 

in  typhus  fever,  2HU. 

abdominal.  In  typhoid  fever,  151. 
Paralysis,  after  cerebro-spinal  ftver. 
221>. 

after  relapsing  fever,  317. 

in  cerebro-spliuil  fever,  22i). 

in  typhoid  fever,  15!>. 

in  typhus  fever,  284. 
Parasitic  tin  ory  of  disease,  24. 
I'arotitis,  in  cerebro-spinal  fever, 
2iW 

in  Influenza,  2-58. 

in  typlioid  fever,  150. 
Particle,  dellnition  of,  21. 
Pasteur,  on  attenuation  of  vlru8(  s, 

305. 
Patient,  attitude  of ,  in  cerebro-spinal 

fever,  230. 
Pea-soup  discharges,  in  typhoid  fe- 
ver, 114. 
Perforation,  intestinal,  in  typhoid 

fever,  151. 
Pernicious  fever,  chart  of,  04. 

clinical  history  of,  80. 

definition  of.  80. 

differential  diagnosis  of,  96. 

etiology  of.  90. 

history  of,  89. 

liypodermatlc  medication  in,  08. 

morbid  anatomy  of,  96. 

prognosis  of,  97. 

synonyms  of  89. 

treatment  of,  97. 

varieties  of,  90. 
Petechise,  in  cerebro-spinal  fever^ 
231. 

in  scarlet  fever,  421. 

in  typhus  fever,  288. 
Physiognomy,  in  pernicious  fever» 
91. 

in  small-pox,  845. 

in  typhoid  fever,  157. 

in  yellow  fever.  203. 


^s>^ms&Wi6iiiiigi^simmim^mMMs^Mi»>Btii> 


il 


INUKX. 


455 


IS. 

lit  tVvn'  .j4. 

fevir,  77. 


rer,  llfi. 

lid  fever,  VA. 
i)-.Hitiiiul  ttver, 

,  :tn. 
er,  iMt. 


ease,  24. 
-spinal  fever,. 


121. 

oil  of  viru8(  8, 

cerebro-apiiial 

In  typhoid  fe- 

,1,  in  typhoid 

t  of,  94. 
0. 

8  of,  OU. 


ation  in,  08. 
90. 


Hspinal  fevei% 


nicious  t'everv 


l>la  nuder,  condition  ..f ,  In  n'rebro-  \ 

nninal  tVver,  -U.  1 

I'lace  of  bacteria  m  v«.Hahle  series,  I 

I'Uix  Hclndeiis,  dwHcnptiou  of,   J-. 
40."). 
In  scarlet  fever.  405. 
IMeurlsy.  in  rfiebr..-si.iiuil  f'VPr.  -..  • 
Pneiiinonla,  iw  a  c>  inpli-  uUun  or  m- 
Uueiiza,  2.")H. 
In  ceiel)io-spinal  fever.  2;>?. 
In  meaHlcH,  :<«'• 
In  relai'sinR  fever,  »3t. 
in  typliold  fever.  W2. 
ill  typlnm  fever,  :i88. 
Pollen,  in  etioloRy  of  lu.yfevei,l-l 
I'lennancy,  in  typlioidfever.nl. 

rreventlon  of  pitting  in  small-P  '^ 

rrojectlle  vomiting,  in  hcarlet  fever. 

408. 
in  yellow  fever,  302. 
Prognosis,  in  cerebro-spinal  fever. 

2.S7. 
ill  chicken-pox,  37a 
in  cluonic  malarial  infection,  lu.', 
in  dengue,  108. 
ill  german  measles,  403. 
in  measles  391. 
in  miliary  fever,  378. 
in  pernicious  fever,  97. 
in  relapsing  fever,  324. 
in  scarlet  fever,  424. 
in  simple  continued  fever,  34. 
in  simple  intermittent  fever,  50. 
in  simple  remittent  fever,  84. 
in  small-pox,  350. 

in  typhoid  fever,  109. 

in  typho-malarial  fever,  119. 

in  typhus  fever,  292. 

in  varioloid,  370, 

in  yellow  fever,  211. 
Prophylaxis,  in  cerebro-spinal  fever, 

239. 
in  chicken-pox,  372. 
in  chronic  malarial  infection,  102. 
in  dengue,  108. 
in  german  measles,  403. 
in  hay  fever,  130. 


In  Inrtnetizai  ^'■''•• 

in  measlei4,!Mtl. 

ill  mirmry  lever,  378. 

Ill  (lernii-K'HH  lever,  87. 

ill  lelapHiug  lever.  324. 

ill  Hcailet  fever,  42.".. 
iiiHiinploconliiHied  fever,  .14. 
in  simple  intennilteiil  lever.  58. 
ill  Hiniple  remittent  lever,  85. 
ill  Hmall-p<"f.;i50. 
ill  lyplioid  lever,  172. 
intyplu'-niiilaiiiU  IVvcr,  ll'.». 
In  typhus  fever,  2i>:i. 
in  varioloid  o70. 
ill  yellow  fever,  211. 
Pulse,  in  eerebro-spinal  lever,  M.. 
in  chronic  malarial  infeetion,  lUl. 
ill  dengue,  105. 
in  inlhienzii,  -oO. 
in  measles,  387. 
in  miliary  fever,  375. 
in  pernicious  fever,  95.  , 

in  relapsing  fever,  Hf'. 
in  scarlet  fever,  410. 
in  simple  continued  fever,  31 . 
in  simple  intermit',  jnt  fever,  54. 
in  simple  remittent  fever,  80. 
in  small-pox,  343. 
in  typhoid  fever,  156. 
in  typho-malarial  fever,  117. 
in  typhus  fever,  287. 
in  yellow  fever,  200. 
Punch,  whisky  or  brandy,  formula 

for,  300.  . 

Pupil,  condition  of,  in  cerebro-spinal 

fever,  229.  .    . 

Putrifaction,  role  of  bacteria  in,  -0. 
Quarantine,  in  small-pox,  351. 
in  relapsing  fever.  ii24. 
in  typhus  fever,  ?  <• 
in  yellow  fever,  212. 
Race,  influence  of.  in  hay  fever,  124. 
in  yellow  fever,  198.       .    ,    .    .  , 
Recrudescences  of  fever,  in  typhoid 

fever,  146. 
Relapses,  in  dengue,  105. 
in  miliary  fever,  375. 
in  relapsing  fever,  279. 
in  typhoid  fever,  ICO. 


aawti 


it 


45G 


INDEX. 


in  typho-malarial  fever,  115. 
in  typhus  fever,  'ITZ. 
Kelapsing  fever,  bacteria  in,  310. 
chart  of,  310. 
clinical  history  of,  312. 
complicationa  of,  315. 
(lelinition  of,  307.  * 

differential  diagnosis  of,  322. 
etiology  of,  .'.09. 
liistory  of,  308. 
morbid  anatomy  of,  320. 
prognosis  of,  32J. 
treatment  of,  324. 
Itenal  complications,  in  relapsing  fe- 
ver, 320. 
in  scarlet  fever,  419. 
in  small-pox,  341. 
in  yellow  tever,  205. 
Remedies  used  hypodermatically,  98. 
lleproductiou  of  bacteria, 20. 
Respiration  of  bacteria,  20. 
Respiratory  system,  condition  of,  in 
cerebro-spinal  fever,  232. 
in  typhoid  fever,  150. 
Retinitis,  in  relapsing  fever,  315.     • 
Re-vaccination,  307. 
Role  of  bacteria  in  causation  of  dis- 
ease, 22. 
Salivary  glands,  changes  in,  in  ty- 
phoid fever,  163. 
Scarlet  fever,  chart  of,  415. 
bacteria  in  blood  of,  421. 
bacteria  in  urine  of,  419. 
clinical  history  of,  407. 
complications  and  sequels  of,  411. 
definition  of,  404. 
dillerential  diagnosis  of,  422. 
duration  of,  409. 
.    etioic^y  of,  405. 
history  of,  404. 
incubation  of,  406. 
ill  the  lower  animals,  400. 
morbid  anatomy  of,  420. 
plax  scindens  in  etiology  of,  405. 
prognosis  of,  424. 
synonyms  of,  404. 
treatment  of,  425. 
Schizomycetes,  in  cerebro-spinal  fe- 
vor.  22,  234. 


Season  of  year  as  predisposing  iuflu- 
once  in  cerebro-spinal  fever,  224. 
in  hay  fever,  124. 
in  typhoid  fever,' 137. 

in  typhus  fever,  274. 

in  yellow  fever,  198. 
Secondary  fever,  in  relapsing  fever, 
314. 

in  small-pox,  338. 
Sewer-gas,  as  a  nause  of  typho-mala- 
rial fever,  112. 
Simple  continued  fever,  chart  of,  32. 

clinical  history  of,  29. 

definition  of,  29. 

diagnosis  of,  33. 

duration  of,  30. 

etioijgyof,29. 

prognosis  of,  34. 

synonvms  of,  29. 

treatment  of,  34. 

varieties  of,  30. 
Simple  intermittent  fever,  chart  of, 
53. 

clinical  history  of,  49. 

bacillus  malaria)  in,  49. 

definition  of,  48. 

differential  diagnosis  of,  55. 

etiology  of,  49. 

history  of,  48. 

morbid  anatomy  of,  54. 

prognosis  of,  56. 

synonyms  of,  48. 

treatment  of,  67. 
Simple  remittent  fever,  chart  of,  81. 

clinical  history  of,  77. 

bacillus  malarise  in,  77. 

definition  of,  76. 

difierential  diagnosis  of,  83. 

duration  of,  85. 

etiology  of,  76. 

historical  notice  of,  78. 

mo  ibid  anatomy  of  82. 

prognosis  of,  84, 

synonyms  of,  76. 

treatment  of,  85. 
■^kin,  appearance  of,  in  cerebro-spi- 
nal fever,  231. 

in  chicken-pox,  371. 

in  chronic  malarial  infection,  101. 


INDEX. 


457 


isposing  iuflu- 
nal  fever,  224. 


lapsing  fever, 


af  typho-mala- 
r,  chart  of,  32. 


'ever,  chart  of, 

,49. 

is  of,  55. 


54. 


sr,  chart  of,  81. 
77. 

is  of,  83.  . 


78. 
82. 


in  cerebro-spi- 
I  infection,  101. 


in  dengue,  106. 
in  german  measles,  400. 
in  influenza,  258. 
in  measles,  387. 
in  miliary  fever,  376. 
in  pernicious  fever,  95. 
in  relapsing  fever,  320. 
in  scarlet  fever,  418. 
in  simple  intermittent  fever,  49 
in  simple  remittent  fever,  78. 
in  small-pox,  345. 
in  typhoid  fever,  157. 
in  typho-malarial  fever,  117. 
in  typhus  fever,  287. 
in  varioloid,  368. 
in  yellow  fever,  203. 
bronzed  hue  of,  in  typho-malarial 
fever,  117.  . 

Sleeplessness,  in  cerebro-spmal  le- 
ver, 228. 
in  typhus  fever,  283. 
Small-pox,  chart  of,  342. 
clinical  history  of,  336. 
complications  of,  341. 
definition  of,  331. 
differential  diagnosis  of,  348. 
duration  of,  341. 
etiology  of,  3.34. 
eruption  of,  343. 
history  of,  332. 
incubation  of,  335. 
inoculation  in,  364. 
micrococci  in,  23, 334. 
morbid  anatomy  of,  347. 
prognosis  of,  350. 
synonyms  of,  332. 
treatment  of.,  350. 
vaccination  in,  365. 
Somnolence  in  typhoid  fever,  158. 
Sordes  in  typhoid  fever,  150. 
Spirillum,  description  of,  17, 810. 

in  relapsing  fever,  310. 
F  Arochseti,  18, 310. 
,  j,ine,  contraction  of  erector  muscles 

of ,  in  cerebro-splnal  fever,  230. 
Spleen,  changes  in,  in  chronic  mala- 
rial infection,  101. 
in  measles,  389. 
in  miliary  fever,  376. 


in  relapsing  fever,  321. 
in  scarlet  fever,  422. 
in  simple  remittent  fever,  83. 
in  typhoid  fever,  162. 
in  typho-malarial  fever,  117. 
in  typhus  fever,  290. 
Sponging,  in  dengue,  109. 
in  german  measles,  403. 
in  measles,  398.  ,    , 

in  scarlet  fever,  439. 

in  small-ppx,  359. 
in  typhoid  fever,  792. 
in  typhus  fever,  305. 
in  yellow  fever,  221. 
Stimulants,  in  cerebro-spinal  fevei, 

252. 
in  influenza,  271. 
in  measles,  398. 
in  pernicious  fever,  99. 
in  relapsing  fever,  329. 
ill  scarlet  fever,  438. 
in  small-pox,  3.59. 
in  typhoid  fever,  194. 

in  typho-malarial  fever,  121. 

in  typhus  fever,  305. 

in  yellow  fever,  221. 
Stomach,  clianges  in,  in  relapsmg 
fever,  321. 

in  simple  remittent  fever,  83. 

in  typhoid  fever,  163. 

in  yellow  fever,  209. 
Structure  of  bacteria,  16. 
Sudamina,  in  cerebro-spinul  fever, 

231. 
in  typhoid  fever,  157. 
Sulphate  of  quinine,  action  of,  upon 
'       bacteria,  59. 

Suppression  of  urine,  in  scarlet  fe- 
ver, 419. 
in  small-pox,  346. 
in  typhoid  fever,  158. 
in  typhus  fever,  289. 
in  yellow  fever,  2C  5. 
Temperature,  in  cercbro-spmal  fe- 
ver, 231. 
in  dengue,  105. 
in  influenza,  256. 
in  measles,  386. 
in  miliary  fever,  375. 


'? 
■'■i 


458 


INDEX. 


in  pernicious  fever,  95. 
in  relapsing  fever,  318. 
in  simple  continued  fever,  31. 
in  simple  intermittent  fever,  54. 
in  simple  remittent  fever,  80. 
in  scarlet  fever,  416. 
in  small-pox,  330. 
in  typhoid  fever,  152. 
in  typho-malarial  fever,  117. 
•    in  typhus  fever,  284. 
in  yellow  fever,  200. 
Tents,  in  treatment,  of  typhus  fever, 
304. 
of  yellow  fever,  212. 
The  parasitic  theory,  24. 
The  bacillus  malariie,  18, 24,  39. 
The  tubercle  bacillus,  23. 
Thirst,  in  cerebro-spinal  fever,  233. 
in  measles,  388. 
in  pernicious  fever,  95. 
in  relapsing  fever,  317. 
in  scarlet  fever,  419. 
in  simple  intermittent  fever,  54. 
in  simple  remittent  fever,  82. 
in  small-pox '346. 
in  typhoid  fever,  150. 
in  typhus  fever,  289.   . 
Thermometry  of  fevers,  46. 
Tongue,  state  of,  in  cerebro-spinal 
fever,  232. 
in  chronic  malarial  infection,  101. 
in  dengue,  106.  ^ 
in  german  measles,  400. 
in  influenza,  268. 
in  measles,  388. 
in  pernicious  fever,  95. 
in  relapsing  fever,  317. 
in  scarlet  fever,  418. 
in  simple  intermittent  fever,  54. 
in  simple  remittent  fever,  82. 
in  small-pox,  845. 
in  typhoid  fever,  148. 
in  typho-malarial  fever,  116. 
in  typhus  fever,  289. 
in  yellow  fever,  203. 
Tremor  in  typhoid  fever,  139. 
Trismus  in  cerebro-spinal  fever,  230 
Treatment,  of  cerebro-spinal  fever 
239. 


of  chicken-pox,  372. 
of  chronic  malarial  infection,  102. 
of  dengue,  108. 
of  german  measles,  408. 
of  hay  fever,  130. 
of  influenza,  259. 
of  measles,  391. 
of  miliary  fever,  378. 
of  pernicious  fever,  97. 
of  relapsing  fever,  324. 
of  simple  continued  fever,  34. 
of  simple  intermittent  fever  57. 
of  simple  remittent  fever,  85. 
of  scarlet  fever,  425. 
of  small-pox,  350. 
of  typhoid  fever.  172. 
of  typho-malarial  fever,  119. 
of  typhus  fever,  293. 
of  varioloid,  370. 
of  yellow  fever,  211. 
Tympanites,  in  typhoid  fever,  152. 
Types,  of  simple  intermittent  fever, 

51. 
of  typho-malarial  fever,  112. 
Typhoid  fever,  abortive  form  of,  147. 
bacteria  in,  138. 
chart  of,  149. 
clinical  history  of,  142. 
definition  of,  136. 
differential  diagnosis  of,  165. 
duration  of,  159. 
etiology  of,  137. 

geographical  distribution  of,  13T. 

history  of,  136. 

incubation  of,  140. 

mild  form  of,  147. 

morbid  anatomy  of,  160. 

prognosis  of,  169. 

synonyms  of,  136. 

treatment  of,  172. 
Typho-malarial  fever,  chart  of,  116. 

clinical  history  of,  112. 

complications  of,  114. 

definition  of.  111. 

differential  diagnosis  of,  118. 

duration  of,  115. 
I    etiology  of,  112. 

history  of ,  112. 
malprial  type  of,  112, 


hjjrtuiiuwiiMHHiiiiui  mm 


1} 

i 


INDEX. 


45^ 


infection,  102. 
403. 


97. 
124. 

[  fever,  34. 
ent  fever  57. 
,  fever,  85. 


'2. 
ever,  119. 


oid  fever,  152. 
jrmittent  fever, 

fever,  112. 

;ive  form  of,  147. 


142. 
isis  of,  165. 

fibution  of,  137. 
)f ,  160. 


er,  chart  of,  116. 

',  112. 

114. 

osis  of,  118. 


112. 


morbid  anatomy  of,  117. 
prognosis  of,  119. 
septic  type  of,  113. 
synonyms  of,  112. 
treatment  of,  119- 
Typhus  fever,  chart  of,  282. 
clinical  history  of,  276. 
complications  of,  279. 
definition  of,  272. 
differential  diagnosis  of,  291. 
duration  of,  281. 
etiology  of,  274. 
geographical  limits  of,  273. 
history  of,  273. 
incubation  of,  275. 
morbid  anatomy  of,  289. 
prognosis  of,  292. 
synonyms  of,  272. 
treatment  of ,  293. 
Urine,  changes  in,  in  cerebro-spmal 
fever,  233. 
in  chronic  malarial  infection,  lui. 
in  influenza,  258. 
in  measles,  388. 
in  miliai7  fever,  375. 
in  relapsing  fever,  320. 
in  scarlet  fever,  419. 
in  simple  continued  fever,  33. 
in  simple  intermittent  fever,  54. 
in  simple  remittent  fever,  78. 
in  small-pox,  346. 
in  typhoid  fever,  158. 
in  typho-malarial  fever,  114. 
in  typhus  fever,  289. 
in  yellow  fever,  205. 
Urticaria,  in  cerebro-spinal  fever, 
231. 
in  dengue,  106. 
Vaccination,  definition  of,  365. 
history  of,  365. 

mortality  by  small-pox  after,  367, 
period  of  performance  of,  866. 
prophylactic  influence  of,  365. 
statistiCB  of,  366. 
surgery  of,  367. 
Vaccinia,  definition  of,  361. 
clinical  history  of,  361. 
complications  of,  863. 
irregularities  of,  862. 


synonyms  of,  361. 
Variable  pulse,  in  cerebro-spinal  fe- 
ver, 232. 
Variations  of  relapsing  fever,  312. 
Varioloid,  chart  of,  369. 
clinical  history  of,  368. 

definition  of,  368. 

differential  diagnosis  of ,  370. 

duration  of,  370. 

etiology  of,  308. 

prognosis  of,  370. 

synomym  of,  368. 

treatment  of  370. 
Vertigo,  in  cerebro-spinal  fever,  229. 

in  relapsing  fever,  315. 

in  sraall-pox,  341. 

in  typhus  fever,  281. 
Vibrios,  description  of,  19. 
Virus,  vaccine,  366. 
Viruses,  15. 
Vomiting,  in  cerebro-spinal  fever, 

333. 
in  chicken-pox,  371. 
in  dengue,  105. 
in  influenza,  258. 
in  measles,  388. 
in  pernicious  fever,  95. 
in  relapsing  fever,  317. 
in  scarlet  fever,  419. 
in  simple  intermittent  fever,  54. 
in  simple  remittent  fever,  82. 
in  small-pox,  346. 
in  typhoid  fever,  150. 
in  typho-malarial  fever,  115. 
in  typhus  fever,  288. 
in  yellow  fever,  205. 
Waterhouse,  the  first  American  vac- 

c  nator,  366.  ,     ^    . 

Waters  which  do  not  contain  bacte- 
ria, 21.  .      .  ' 
Weight  of  body,  changes  m,  m  ty- 
phoid fever,  157. 
in  relapsing  fever,  314. 
Wine-whey,  formula  for,  194. 
Yellow  fever,  chart  of,  204. 
clinical  history  of,  200. 
definition  of,  195. 
I    differential  diagnosis  of,  210. 
I    duration  of,  203. 


'i 

1 

m — - 

1} 

i 

460 


INDEX. 


etiology  of,  196. 
geographical  limits  of,  196. 
history  of,  19o. 
incubation  of,  200. 


morbid  anatomy  of,  208. 
prognosis  of,  211. 
synonyms  of,  195. 
treatment  of,  211. 


arc 


mssmsm 


If 

> 


of,  208. 


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THE  PHYSICIAN'S  DAY-BOOK  AND  LEDGER. 

Arranged  by  T.  D.  Wn.uABi8,  M.D.  220  pages.  Price  f 2.00.  Sample 
pages  sent  on  application. 

Label-Book,  for  The  Use  of  Physicians  and  Pharmacists. 

Containing  more  than  thirty-five  hundred  gummed  labels,  in  large,  dear 
type,  and  bound  in  a  neat  and  snlmtantial  manner.  Price  M)  ots.  Sent 
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Th«  abwoe  Worla  can  be  had  at  all  Homaopathic  Pharmaein,  or  will  be  sent 

prepaid  on  rmHpt.  of  price.     Address,  Oaoas  &  Dblbbidmb, 

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eir  Homoeopathic 
if  Sargery  in  the 
1 ;  Burgeon  to  the 
)  and  Art  of  Snr- 
9.    Ootavo.    1888. 


ietry  and  Toxiool- 
uraal  of  Urinary 
,  Oloth.    206  pp. 


I  Saint  Jaoqaes, 
DLAH,  M.D.,  Pro- 
1  and  of  Clinioal 
ipital  of  Chicago. 
BO  |6.00. 


mceopathio  Doee- 
tleasnreB,  Memo- 
ity  of  Medicines, 
inations,  Homcoo- 
y  Sahubi.  O.  L. 
ther  Tack,  |2.60. 

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lecessity  of  sepa- 
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$8.60. 


f2.00.     Sample 


lacists. 

Is,  in  larg«,  dear 
rice  50  ets.    Saiii 


m,  or  v/iU  be  sent 


V 


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.* 


